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Similar Outcomes for Patients Discharged on Weekends vs. Weekdays
Inpatients discharged from teaching hospitals on weekends experience similar postdischarge outcomes and shorter lengths of stay compared with patients discharged on weekdays, according to a recent Journal of Hospital Medicine study.
The study, led by Finlay McAlister, MSc, MD, LMCC, general internist and population health investigator at the Alberta Heritage Foundation for Medical Research in Canada, examined death or nonelective readmission rates for general medicine inpatients 30 days after weekend and weekday discharges at all seven teaching hospitals in Alberta.
Although fewer pharmacists, physicians, and therapists typically are available to assist patients discharged on weekends, Dr. McAlister and colleagues found that patients sent home on weekends do not bounce back to the hospital or the ED sooner than patients sent home on weekdays.
"If somebody is ready to go [home] on a weekend, you do not have to hold them until Monday, and nurse them and give them a false impression that that will improve their 30-day outcome," Dr. McAlister says.
In a previous study of patients with heart failure, Dr. McAlister noticed a trend that suggested better outcomes for patients discharged on weekdays. However, after studying a wider spectrum of patients with various diagnoses, he concluded there is no difference between weekend and weekday discharges in terms of patients' 30-day outcome.
Dr. McAlister suggests more research can be done to determine whether there is a difference in outcomes for weekend discharges from nonteaching hospitals.
"Because teaching hospitals may be a bit of a safety net, in terms of having house staff that is there seven days a week," he says. "The impact of reduced staffing levels may be more severe than at nonteaching hospitals."
Visit our website for more information on patient-discharge recommendations.
Inpatients discharged from teaching hospitals on weekends experience similar postdischarge outcomes and shorter lengths of stay compared with patients discharged on weekdays, according to a recent Journal of Hospital Medicine study.
The study, led by Finlay McAlister, MSc, MD, LMCC, general internist and population health investigator at the Alberta Heritage Foundation for Medical Research in Canada, examined death or nonelective readmission rates for general medicine inpatients 30 days after weekend and weekday discharges at all seven teaching hospitals in Alberta.
Although fewer pharmacists, physicians, and therapists typically are available to assist patients discharged on weekends, Dr. McAlister and colleagues found that patients sent home on weekends do not bounce back to the hospital or the ED sooner than patients sent home on weekdays.
"If somebody is ready to go [home] on a weekend, you do not have to hold them until Monday, and nurse them and give them a false impression that that will improve their 30-day outcome," Dr. McAlister says.
In a previous study of patients with heart failure, Dr. McAlister noticed a trend that suggested better outcomes for patients discharged on weekdays. However, after studying a wider spectrum of patients with various diagnoses, he concluded there is no difference between weekend and weekday discharges in terms of patients' 30-day outcome.
Dr. McAlister suggests more research can be done to determine whether there is a difference in outcomes for weekend discharges from nonteaching hospitals.
"Because teaching hospitals may be a bit of a safety net, in terms of having house staff that is there seven days a week," he says. "The impact of reduced staffing levels may be more severe than at nonteaching hospitals."
Visit our website for more information on patient-discharge recommendations.
Inpatients discharged from teaching hospitals on weekends experience similar postdischarge outcomes and shorter lengths of stay compared with patients discharged on weekdays, according to a recent Journal of Hospital Medicine study.
The study, led by Finlay McAlister, MSc, MD, LMCC, general internist and population health investigator at the Alberta Heritage Foundation for Medical Research in Canada, examined death or nonelective readmission rates for general medicine inpatients 30 days after weekend and weekday discharges at all seven teaching hospitals in Alberta.
Although fewer pharmacists, physicians, and therapists typically are available to assist patients discharged on weekends, Dr. McAlister and colleagues found that patients sent home on weekends do not bounce back to the hospital or the ED sooner than patients sent home on weekdays.
"If somebody is ready to go [home] on a weekend, you do not have to hold them until Monday, and nurse them and give them a false impression that that will improve their 30-day outcome," Dr. McAlister says.
In a previous study of patients with heart failure, Dr. McAlister noticed a trend that suggested better outcomes for patients discharged on weekdays. However, after studying a wider spectrum of patients with various diagnoses, he concluded there is no difference between weekend and weekday discharges in terms of patients' 30-day outcome.
Dr. McAlister suggests more research can be done to determine whether there is a difference in outcomes for weekend discharges from nonteaching hospitals.
"Because teaching hospitals may be a bit of a safety net, in terms of having house staff that is there seven days a week," he says. "The impact of reduced staffing levels may be more severe than at nonteaching hospitals."
Visit our website for more information on patient-discharge recommendations.
Threat of Facility Closure Puts Pressure on Rural Hospitalists
A pair of rural South Carolina hospitals that may soon shutter their doors is the latest example of the pressure on rural hospitalists, says a veteran HM director. But hospital closures also give rural hospitalists the opportunity to carve out a niche doing medical work that best serves their community.
Marlboro Park Hospital and Chesterfield General Hospital, 15 miles apart in northeastern South Carolina, are set to close this spring as Community Health Systems—which runs the hospitals and employs hospital staff—announced it would not renew its operating lease. A new operator is being sought.
The fear of a rural institution closing is a common one for hospitalists, says Dana Giarrizzi, DO, FHM, national medical director for telehospitalist services for Eagle Hospital Physicians and section leader for the rural section of SHM.
"There's always that feeling of walking the tightrope," Dr. Giarrizzi says. "It's a fine line because you can't offer everything…there aren't enough physicians."
And while hospitals' shrinking bottom lines, more intensive reporting and quality protocols, and ongoing changes to the rules of the Affordable Care Act have roiled rural hospitalists, Dr. Giarrizzi sees the current environment as one that offers rural groups an opportunity to focus on what they do best and home in on that.
"It's really important [for rural hospitalist groups] to figure out what their niche is, figure out what works for them, and then to run that well," Dr. Giarrizzi adds. "I think it hurts them when they're pushed or when they feel like they have to do everything…you don't have that ability. These small rural hospitals serve their purpose, but their purpose isn't to serve everything."
Visit our website for more information on rural hospitals.
A pair of rural South Carolina hospitals that may soon shutter their doors is the latest example of the pressure on rural hospitalists, says a veteran HM director. But hospital closures also give rural hospitalists the opportunity to carve out a niche doing medical work that best serves their community.
Marlboro Park Hospital and Chesterfield General Hospital, 15 miles apart in northeastern South Carolina, are set to close this spring as Community Health Systems—which runs the hospitals and employs hospital staff—announced it would not renew its operating lease. A new operator is being sought.
The fear of a rural institution closing is a common one for hospitalists, says Dana Giarrizzi, DO, FHM, national medical director for telehospitalist services for Eagle Hospital Physicians and section leader for the rural section of SHM.
"There's always that feeling of walking the tightrope," Dr. Giarrizzi says. "It's a fine line because you can't offer everything…there aren't enough physicians."
And while hospitals' shrinking bottom lines, more intensive reporting and quality protocols, and ongoing changes to the rules of the Affordable Care Act have roiled rural hospitalists, Dr. Giarrizzi sees the current environment as one that offers rural groups an opportunity to focus on what they do best and home in on that.
"It's really important [for rural hospitalist groups] to figure out what their niche is, figure out what works for them, and then to run that well," Dr. Giarrizzi adds. "I think it hurts them when they're pushed or when they feel like they have to do everything…you don't have that ability. These small rural hospitals serve their purpose, but their purpose isn't to serve everything."
Visit our website for more information on rural hospitals.
A pair of rural South Carolina hospitals that may soon shutter their doors is the latest example of the pressure on rural hospitalists, says a veteran HM director. But hospital closures also give rural hospitalists the opportunity to carve out a niche doing medical work that best serves their community.
Marlboro Park Hospital and Chesterfield General Hospital, 15 miles apart in northeastern South Carolina, are set to close this spring as Community Health Systems—which runs the hospitals and employs hospital staff—announced it would not renew its operating lease. A new operator is being sought.
The fear of a rural institution closing is a common one for hospitalists, says Dana Giarrizzi, DO, FHM, national medical director for telehospitalist services for Eagle Hospital Physicians and section leader for the rural section of SHM.
"There's always that feeling of walking the tightrope," Dr. Giarrizzi says. "It's a fine line because you can't offer everything…there aren't enough physicians."
And while hospitals' shrinking bottom lines, more intensive reporting and quality protocols, and ongoing changes to the rules of the Affordable Care Act have roiled rural hospitalists, Dr. Giarrizzi sees the current environment as one that offers rural groups an opportunity to focus on what they do best and home in on that.
"It's really important [for rural hospitalist groups] to figure out what their niche is, figure out what works for them, and then to run that well," Dr. Giarrizzi adds. "I think it hurts them when they're pushed or when they feel like they have to do everything…you don't have that ability. These small rural hospitals serve their purpose, but their purpose isn't to serve everything."
Visit our website for more information on rural hospitals.
Hospitalists Valuable Assets in Fight against Global Health Inequality
Hospitalists should not only lead efforts to control potential Ebola outbreaks in the U.S. but should also play a role in improving global healthcare, say the authors of a recent article in the Journal of Hospital Medicine.
Author Phuoc Le, MD, MPH, assistant professor of medicine and pediatrics at the University of California San Francisco where he co-directs the Global Health-Hospital Medicine Fellowship, is also cofounder of the HEAL Initiative, a global healthcare campaign designed to improve the health of vulnerable populations worldwide. HEAL, short for Health, Equity, Action, and Leadership, recently won the 2015 SHM Award for Excellence in Humanitarian Service.
Dr. Le recently spoke with TH about why hospitalists are well-equipped to handle global health problems.
Question: In your paper, you call on hospitalists to join the ranks of global health hospitalists. Can you explain?
Answer: Whether it’s Navajo Nation in Arizona or rural Haiti, the healthcare needs of the poor are very similar. Global health hospitalists play an important role in building capacity, running a health system, improving quality while reducing costs, working in teams to provide holistic care for the inpatient, and improving transitions to the outpatient setting.
Q: How do the skills learned in resource-poor settings apply back home?
A: Let's say you have a patient with tuberculosis, which is very common in places like Liberia, and you suspect fluid in the lungs. [In Liberia], you would insert a needle and remove the fluid. In the U.S., a lot of providers would not be able to remove the fluid without getting an ultrasound and multiple other studies. Those costs add up. Global health hospitalists are very well-versed in the skills of ultrasonography because there are no ultrasonographers in the field working with us.
Q: You've spent time in Haiti and said that is where you began to notice volunteers arriving with good intentions but without needed skills. What exactly did you learn?
A: I spent a lot of time there, responding to the earthquake and also the cholera epidemic in 2010. I came across dozens of healthcare volunteers who had passion and commitment but really came ill-prepared, not through any fault of their own but because they never had an opportunity to learn the skills needed to be effective in the field. For example, take a nurse from an ivory-tower hospital and suddenly put her where she doesn’t have IVs to work with or the right type of fluids or tubing. Well, suddenly she feels like her efficacy has gone way down. That could easily lead to a lot of frustration and potential burnout. That’s why we started the HEAL Initiative, which is a two-year program for healthcare workers who want to learn the skills needed to work in poor settings.
Q: How can hospitalists get involved in global health?
A: Come to the Society of Hospital Medicine annual meeting in March where we’ll be hosting a special-interest session called Global Health and Human Rights.
Visit our website for more information about global health hospitalists.
Hospitalists should not only lead efforts to control potential Ebola outbreaks in the U.S. but should also play a role in improving global healthcare, say the authors of a recent article in the Journal of Hospital Medicine.
Author Phuoc Le, MD, MPH, assistant professor of medicine and pediatrics at the University of California San Francisco where he co-directs the Global Health-Hospital Medicine Fellowship, is also cofounder of the HEAL Initiative, a global healthcare campaign designed to improve the health of vulnerable populations worldwide. HEAL, short for Health, Equity, Action, and Leadership, recently won the 2015 SHM Award for Excellence in Humanitarian Service.
Dr. Le recently spoke with TH about why hospitalists are well-equipped to handle global health problems.
Question: In your paper, you call on hospitalists to join the ranks of global health hospitalists. Can you explain?
Answer: Whether it’s Navajo Nation in Arizona or rural Haiti, the healthcare needs of the poor are very similar. Global health hospitalists play an important role in building capacity, running a health system, improving quality while reducing costs, working in teams to provide holistic care for the inpatient, and improving transitions to the outpatient setting.
Q: How do the skills learned in resource-poor settings apply back home?
A: Let's say you have a patient with tuberculosis, which is very common in places like Liberia, and you suspect fluid in the lungs. [In Liberia], you would insert a needle and remove the fluid. In the U.S., a lot of providers would not be able to remove the fluid without getting an ultrasound and multiple other studies. Those costs add up. Global health hospitalists are very well-versed in the skills of ultrasonography because there are no ultrasonographers in the field working with us.
Q: You've spent time in Haiti and said that is where you began to notice volunteers arriving with good intentions but without needed skills. What exactly did you learn?
A: I spent a lot of time there, responding to the earthquake and also the cholera epidemic in 2010. I came across dozens of healthcare volunteers who had passion and commitment but really came ill-prepared, not through any fault of their own but because they never had an opportunity to learn the skills needed to be effective in the field. For example, take a nurse from an ivory-tower hospital and suddenly put her where she doesn’t have IVs to work with or the right type of fluids or tubing. Well, suddenly she feels like her efficacy has gone way down. That could easily lead to a lot of frustration and potential burnout. That’s why we started the HEAL Initiative, which is a two-year program for healthcare workers who want to learn the skills needed to work in poor settings.
Q: How can hospitalists get involved in global health?
A: Come to the Society of Hospital Medicine annual meeting in March where we’ll be hosting a special-interest session called Global Health and Human Rights.
Visit our website for more information about global health hospitalists.
Hospitalists should not only lead efforts to control potential Ebola outbreaks in the U.S. but should also play a role in improving global healthcare, say the authors of a recent article in the Journal of Hospital Medicine.
Author Phuoc Le, MD, MPH, assistant professor of medicine and pediatrics at the University of California San Francisco where he co-directs the Global Health-Hospital Medicine Fellowship, is also cofounder of the HEAL Initiative, a global healthcare campaign designed to improve the health of vulnerable populations worldwide. HEAL, short for Health, Equity, Action, and Leadership, recently won the 2015 SHM Award for Excellence in Humanitarian Service.
Dr. Le recently spoke with TH about why hospitalists are well-equipped to handle global health problems.
Question: In your paper, you call on hospitalists to join the ranks of global health hospitalists. Can you explain?
Answer: Whether it’s Navajo Nation in Arizona or rural Haiti, the healthcare needs of the poor are very similar. Global health hospitalists play an important role in building capacity, running a health system, improving quality while reducing costs, working in teams to provide holistic care for the inpatient, and improving transitions to the outpatient setting.
Q: How do the skills learned in resource-poor settings apply back home?
A: Let's say you have a patient with tuberculosis, which is very common in places like Liberia, and you suspect fluid in the lungs. [In Liberia], you would insert a needle and remove the fluid. In the U.S., a lot of providers would not be able to remove the fluid without getting an ultrasound and multiple other studies. Those costs add up. Global health hospitalists are very well-versed in the skills of ultrasonography because there are no ultrasonographers in the field working with us.
Q: You've spent time in Haiti and said that is where you began to notice volunteers arriving with good intentions but without needed skills. What exactly did you learn?
A: I spent a lot of time there, responding to the earthquake and also the cholera epidemic in 2010. I came across dozens of healthcare volunteers who had passion and commitment but really came ill-prepared, not through any fault of their own but because they never had an opportunity to learn the skills needed to be effective in the field. For example, take a nurse from an ivory-tower hospital and suddenly put her where she doesn’t have IVs to work with or the right type of fluids or tubing. Well, suddenly she feels like her efficacy has gone way down. That could easily lead to a lot of frustration and potential burnout. That’s why we started the HEAL Initiative, which is a two-year program for healthcare workers who want to learn the skills needed to work in poor settings.
Q: How can hospitalists get involved in global health?
A: Come to the Society of Hospital Medicine annual meeting in March where we’ll be hosting a special-interest session called Global Health and Human Rights.
Visit our website for more information about global health hospitalists.
Hospitalists Optimistic over ABIM Changes to Maintenance of Certification Requirements
News that the American Board of Internal Medicine (ABIM) will reboot its controversial Maintenance of Certification (MOC) program is an opportunity for hospitalists to help shape their own professional development, according to former ABIM chair and hospital medicine pioneer Robert Wachter, MD, MHM.
A year ago, ABIM moved from an MOC every 10 years to a more continuous certification process. The goal was to keep physicians more current, but the change sparked backlash over education costs, the applicability and usefulness of exam questions, and bureaucratic burdens of the new process.
In a public statement last week, ABIM president and CEO Richard Baron, MD, acknowledged that "ABIM clearly got it wrong. We launched programs that weren't ready and we didn't deliver an MOC program that physicians found meaningful."
Dr. Wachter, who was ABIM's chair when Dr. Baron was hired, says that ABIM's new plan to reach out to specialty societies means SHM can lobby for an MOC process that is more current, more applicable, and more meaningful to practitioners. Given that HM as a specialty was launched as a novel idea on what would make a good care model for hospitalized patients, Dr. Wachter is confident that SHM can be helpful in guiding the creation of a better MOC process.
Hospital medicine "was built on out-of-the-box thinking, on accepting certain parts of the old model of what a good doctor was but throwing other parts out and saying, 'We want to rethink this,'" Dr. Wachter says. "I can't think of a specialty that’s better positioned to help."
Meanwhile, hospitalist and ABIM Council member Jeff Wiese, MD, MHM, sees an opportunity to make sure the overall process for "knowledge improvement" is enhanced so that disconnects between practitioners and ABIM do not continue.
"We have to ensure that what happened over the past 20 years doesn't happen again," Dr. Wiese says. "Namely, that the world of medicine doesn't move so fast that the ABIM MOC requirements don't keep up. If we engage as physicians and specialty organizations in meaningful dialogues…then we have a much better chance of making MOC sufficiently dynamic to meet the changing times."
SHM President Burke Kealey, MD, SFHM, says that hospitalists were less impacted than some other specialists by the MOC change because they could use the Focused Practice in Hospital Medicine (FPHM) exam. The FPHM test was crafted by "real practicing hospitalists [writing] the questions for hospitalists from the point of view of what a hospitalist needs to know to do their job," he says.
Dr. Kealey adds that SHM plans to help hospitalists prepare for exams through courses featured at next month’s annual meeting and with the publication of a study guide due out this fall focused on the test's nonclinical aspects. Since it was posted last week, Dr. Kealey's blog on "The Hospital Leader" has attracted the interest of thousands of hospitalists and has been shared more than 70 times.
Visit our website for more information on Maintenance of Certification issues.
News that the American Board of Internal Medicine (ABIM) will reboot its controversial Maintenance of Certification (MOC) program is an opportunity for hospitalists to help shape their own professional development, according to former ABIM chair and hospital medicine pioneer Robert Wachter, MD, MHM.
A year ago, ABIM moved from an MOC every 10 years to a more continuous certification process. The goal was to keep physicians more current, but the change sparked backlash over education costs, the applicability and usefulness of exam questions, and bureaucratic burdens of the new process.
In a public statement last week, ABIM president and CEO Richard Baron, MD, acknowledged that "ABIM clearly got it wrong. We launched programs that weren't ready and we didn't deliver an MOC program that physicians found meaningful."
Dr. Wachter, who was ABIM's chair when Dr. Baron was hired, says that ABIM's new plan to reach out to specialty societies means SHM can lobby for an MOC process that is more current, more applicable, and more meaningful to practitioners. Given that HM as a specialty was launched as a novel idea on what would make a good care model for hospitalized patients, Dr. Wachter is confident that SHM can be helpful in guiding the creation of a better MOC process.
Hospital medicine "was built on out-of-the-box thinking, on accepting certain parts of the old model of what a good doctor was but throwing other parts out and saying, 'We want to rethink this,'" Dr. Wachter says. "I can't think of a specialty that’s better positioned to help."
Meanwhile, hospitalist and ABIM Council member Jeff Wiese, MD, MHM, sees an opportunity to make sure the overall process for "knowledge improvement" is enhanced so that disconnects between practitioners and ABIM do not continue.
"We have to ensure that what happened over the past 20 years doesn't happen again," Dr. Wiese says. "Namely, that the world of medicine doesn't move so fast that the ABIM MOC requirements don't keep up. If we engage as physicians and specialty organizations in meaningful dialogues…then we have a much better chance of making MOC sufficiently dynamic to meet the changing times."
SHM President Burke Kealey, MD, SFHM, says that hospitalists were less impacted than some other specialists by the MOC change because they could use the Focused Practice in Hospital Medicine (FPHM) exam. The FPHM test was crafted by "real practicing hospitalists [writing] the questions for hospitalists from the point of view of what a hospitalist needs to know to do their job," he says.
Dr. Kealey adds that SHM plans to help hospitalists prepare for exams through courses featured at next month’s annual meeting and with the publication of a study guide due out this fall focused on the test's nonclinical aspects. Since it was posted last week, Dr. Kealey's blog on "The Hospital Leader" has attracted the interest of thousands of hospitalists and has been shared more than 70 times.
Visit our website for more information on Maintenance of Certification issues.
News that the American Board of Internal Medicine (ABIM) will reboot its controversial Maintenance of Certification (MOC) program is an opportunity for hospitalists to help shape their own professional development, according to former ABIM chair and hospital medicine pioneer Robert Wachter, MD, MHM.
A year ago, ABIM moved from an MOC every 10 years to a more continuous certification process. The goal was to keep physicians more current, but the change sparked backlash over education costs, the applicability and usefulness of exam questions, and bureaucratic burdens of the new process.
In a public statement last week, ABIM president and CEO Richard Baron, MD, acknowledged that "ABIM clearly got it wrong. We launched programs that weren't ready and we didn't deliver an MOC program that physicians found meaningful."
Dr. Wachter, who was ABIM's chair when Dr. Baron was hired, says that ABIM's new plan to reach out to specialty societies means SHM can lobby for an MOC process that is more current, more applicable, and more meaningful to practitioners. Given that HM as a specialty was launched as a novel idea on what would make a good care model for hospitalized patients, Dr. Wachter is confident that SHM can be helpful in guiding the creation of a better MOC process.
Hospital medicine "was built on out-of-the-box thinking, on accepting certain parts of the old model of what a good doctor was but throwing other parts out and saying, 'We want to rethink this,'" Dr. Wachter says. "I can't think of a specialty that’s better positioned to help."
Meanwhile, hospitalist and ABIM Council member Jeff Wiese, MD, MHM, sees an opportunity to make sure the overall process for "knowledge improvement" is enhanced so that disconnects between practitioners and ABIM do not continue.
"We have to ensure that what happened over the past 20 years doesn't happen again," Dr. Wiese says. "Namely, that the world of medicine doesn't move so fast that the ABIM MOC requirements don't keep up. If we engage as physicians and specialty organizations in meaningful dialogues…then we have a much better chance of making MOC sufficiently dynamic to meet the changing times."
SHM President Burke Kealey, MD, SFHM, says that hospitalists were less impacted than some other specialists by the MOC change because they could use the Focused Practice in Hospital Medicine (FPHM) exam. The FPHM test was crafted by "real practicing hospitalists [writing] the questions for hospitalists from the point of view of what a hospitalist needs to know to do their job," he says.
Dr. Kealey adds that SHM plans to help hospitalists prepare for exams through courses featured at next month’s annual meeting and with the publication of a study guide due out this fall focused on the test's nonclinical aspects. Since it was posted last week, Dr. Kealey's blog on "The Hospital Leader" has attracted the interest of thousands of hospitalists and has been shared more than 70 times.
Visit our website for more information on Maintenance of Certification issues.
Procalcitonin-Based Algorithm Does Not Reduce Antibiotic Use in the ICU
Clinical question
Can a procalcitonin-based algorithm reduce antibiotic use in critically ill patients?
Bottom line
A procalcitonin-based algorithm using a 0.1 ng/mL cutoff does not significantly decrease the duration of antibiotic treatment in critically ill patients nor does it reduce length of stay or number of deaths. The rate of decline in the procalcitonin level over the first 72 hours, however, does serve as an independent predictor of short-term and long-term all-cause mortality. (LOE = 1b-)
Reference
Study design: Randomized controlled trial (nonblinded)
Funding source: Foundation
Allocation: Concealed
Setting: Inpatient (ICU only)
Synopsis
Procalcitonin (PCT) is a sepsis biomarker that has been utilized to guide antibiotic use in different patient populations. In this study, the authors tested a PCT-algorithm using a 0.1 ng/mL cut-off to reduce antibiotic exposure in critically ill patients. Patients newly admitted to intensive care units (ICUs) who were receiving antibiotics for suspected infections were randomized, using concealed allocation, to receive PCT-guided care (n = 196) or standard care (n = 198). All patients had PCT levels drawn daily until discharge from the ICU or up to a maximum of 7 days. In the PCT group, antibiotics were stopped if PCT levels were negative (< 0.1 ng/mL), if PCT levels were borderline (0.1 - 0.25 ng/mL) and infection was unlikely, or if PCT levels decreased more than 90% from baseline values. In the standard care group, the treating clinician determined antibiotic use without knowledge of the PCT results. Baseline characteristics of the 2 groups were similar with regard to severity-of-disease scores and baseline PCT values. There was high compliance with the PCT algorithm, with less than 3% of study days when the algorithm was not followed. There was no significant difference detected between the 2 groups for the primary outcome of time to antibiotic cessation. However, duration of antibiotic use was longer than expected in the control group (11 days actual vs 9 days expected), so the study may have been underpowered to detect an expected 25% reduction. Nevertheless, the 2 groups were similar with regard to ICU and hospital lengths of stay, as well as ICU, hospital, and 90-day mortality rates. Of note, the rate of decline in PCT level over the first 72 hours was an independent predictor of hospital mortality and 90-day mortality, with a slower decline corresponding to a higher mortality.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Can a procalcitonin-based algorithm reduce antibiotic use in critically ill patients?
Bottom line
A procalcitonin-based algorithm using a 0.1 ng/mL cutoff does not significantly decrease the duration of antibiotic treatment in critically ill patients nor does it reduce length of stay or number of deaths. The rate of decline in the procalcitonin level over the first 72 hours, however, does serve as an independent predictor of short-term and long-term all-cause mortality. (LOE = 1b-)
Reference
Study design: Randomized controlled trial (nonblinded)
Funding source: Foundation
Allocation: Concealed
Setting: Inpatient (ICU only)
Synopsis
Procalcitonin (PCT) is a sepsis biomarker that has been utilized to guide antibiotic use in different patient populations. In this study, the authors tested a PCT-algorithm using a 0.1 ng/mL cut-off to reduce antibiotic exposure in critically ill patients. Patients newly admitted to intensive care units (ICUs) who were receiving antibiotics for suspected infections were randomized, using concealed allocation, to receive PCT-guided care (n = 196) or standard care (n = 198). All patients had PCT levels drawn daily until discharge from the ICU or up to a maximum of 7 days. In the PCT group, antibiotics were stopped if PCT levels were negative (< 0.1 ng/mL), if PCT levels were borderline (0.1 - 0.25 ng/mL) and infection was unlikely, or if PCT levels decreased more than 90% from baseline values. In the standard care group, the treating clinician determined antibiotic use without knowledge of the PCT results. Baseline characteristics of the 2 groups were similar with regard to severity-of-disease scores and baseline PCT values. There was high compliance with the PCT algorithm, with less than 3% of study days when the algorithm was not followed. There was no significant difference detected between the 2 groups for the primary outcome of time to antibiotic cessation. However, duration of antibiotic use was longer than expected in the control group (11 days actual vs 9 days expected), so the study may have been underpowered to detect an expected 25% reduction. Nevertheless, the 2 groups were similar with regard to ICU and hospital lengths of stay, as well as ICU, hospital, and 90-day mortality rates. Of note, the rate of decline in PCT level over the first 72 hours was an independent predictor of hospital mortality and 90-day mortality, with a slower decline corresponding to a higher mortality.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Can a procalcitonin-based algorithm reduce antibiotic use in critically ill patients?
Bottom line
A procalcitonin-based algorithm using a 0.1 ng/mL cutoff does not significantly decrease the duration of antibiotic treatment in critically ill patients nor does it reduce length of stay or number of deaths. The rate of decline in the procalcitonin level over the first 72 hours, however, does serve as an independent predictor of short-term and long-term all-cause mortality. (LOE = 1b-)
Reference
Study design: Randomized controlled trial (nonblinded)
Funding source: Foundation
Allocation: Concealed
Setting: Inpatient (ICU only)
Synopsis
Procalcitonin (PCT) is a sepsis biomarker that has been utilized to guide antibiotic use in different patient populations. In this study, the authors tested a PCT-algorithm using a 0.1 ng/mL cut-off to reduce antibiotic exposure in critically ill patients. Patients newly admitted to intensive care units (ICUs) who were receiving antibiotics for suspected infections were randomized, using concealed allocation, to receive PCT-guided care (n = 196) or standard care (n = 198). All patients had PCT levels drawn daily until discharge from the ICU or up to a maximum of 7 days. In the PCT group, antibiotics were stopped if PCT levels were negative (< 0.1 ng/mL), if PCT levels were borderline (0.1 - 0.25 ng/mL) and infection was unlikely, or if PCT levels decreased more than 90% from baseline values. In the standard care group, the treating clinician determined antibiotic use without knowledge of the PCT results. Baseline characteristics of the 2 groups were similar with regard to severity-of-disease scores and baseline PCT values. There was high compliance with the PCT algorithm, with less than 3% of study days when the algorithm was not followed. There was no significant difference detected between the 2 groups for the primary outcome of time to antibiotic cessation. However, duration of antibiotic use was longer than expected in the control group (11 days actual vs 9 days expected), so the study may have been underpowered to detect an expected 25% reduction. Nevertheless, the 2 groups were similar with regard to ICU and hospital lengths of stay, as well as ICU, hospital, and 90-day mortality rates. Of note, the rate of decline in PCT level over the first 72 hours was an independent predictor of hospital mortality and 90-day mortality, with a slower decline corresponding to a higher mortality.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Early Tube Feeding Does Not Improve Outcomes in Acute Pancreatitis
Clinical question
Does early nasoenteric feeding decrease the rate of infections or death in patients hospitalized with severe acute pancreatitis?
Bottom line
In patients with severe acute pancreatitis, early nasoenteric feeding initiated within 24 hours of presentation, as compared with oral feeding after 72 hours, does not improve mortality or reduce the rate of major infections. (LOE = 1b-)
Reference
Study design: Randomized controlled trial (nonblinded)
Funding source: Government
Allocation: Concealed
Setting: Inpatient (ward only)
Synopsis
Previous observational studies suggest that early nasoenteric feeding in patients with acute pancreatitis may reduce the rate of major infections by stimulating intestinal motility, reducing bacterial overgrowth, and increasing splanchnic blood flow. Using concealed allocation, these authors randomized patients presenting to the emergency department with severe acute pancreatitis to receive either early nasoenteric tube feeding initiated within 24 hours (n = 102) or oral feeding started at 72 hours (n = 106). If the oral diet was not tolerated, tube feeding was initiated after 96 hours. The 2 groups were similar at baseline: the mean age was 65 years and 60% of the patients had evidence of systemic inflammatory response syndrome (SIRS). Analysis was by intention to treat. One third of patients in the oral group eventually required tube feeding. For the primary composite end point of death or major infection (infected pancreatic necrosis, bacteremia, or pneumonia), there was no significant difference detected between the 2 groups. When the outcomes of major infection and death were examined separately, the 2 groups again had comparable results. Finally, patients in both groups had similar rates of admission to the intensive care unit and similar need for mechanical ventilation. Given fewer-than-expected events in the control group, it is possible that the study was too small to detect a difference in the primary outcome, if such a difference exists.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Does early nasoenteric feeding decrease the rate of infections or death in patients hospitalized with severe acute pancreatitis?
Bottom line
In patients with severe acute pancreatitis, early nasoenteric feeding initiated within 24 hours of presentation, as compared with oral feeding after 72 hours, does not improve mortality or reduce the rate of major infections. (LOE = 1b-)
Reference
Study design: Randomized controlled trial (nonblinded)
Funding source: Government
Allocation: Concealed
Setting: Inpatient (ward only)
Synopsis
Previous observational studies suggest that early nasoenteric feeding in patients with acute pancreatitis may reduce the rate of major infections by stimulating intestinal motility, reducing bacterial overgrowth, and increasing splanchnic blood flow. Using concealed allocation, these authors randomized patients presenting to the emergency department with severe acute pancreatitis to receive either early nasoenteric tube feeding initiated within 24 hours (n = 102) or oral feeding started at 72 hours (n = 106). If the oral diet was not tolerated, tube feeding was initiated after 96 hours. The 2 groups were similar at baseline: the mean age was 65 years and 60% of the patients had evidence of systemic inflammatory response syndrome (SIRS). Analysis was by intention to treat. One third of patients in the oral group eventually required tube feeding. For the primary composite end point of death or major infection (infected pancreatic necrosis, bacteremia, or pneumonia), there was no significant difference detected between the 2 groups. When the outcomes of major infection and death were examined separately, the 2 groups again had comparable results. Finally, patients in both groups had similar rates of admission to the intensive care unit and similar need for mechanical ventilation. Given fewer-than-expected events in the control group, it is possible that the study was too small to detect a difference in the primary outcome, if such a difference exists.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Does early nasoenteric feeding decrease the rate of infections or death in patients hospitalized with severe acute pancreatitis?
Bottom line
In patients with severe acute pancreatitis, early nasoenteric feeding initiated within 24 hours of presentation, as compared with oral feeding after 72 hours, does not improve mortality or reduce the rate of major infections. (LOE = 1b-)
Reference
Study design: Randomized controlled trial (nonblinded)
Funding source: Government
Allocation: Concealed
Setting: Inpatient (ward only)
Synopsis
Previous observational studies suggest that early nasoenteric feeding in patients with acute pancreatitis may reduce the rate of major infections by stimulating intestinal motility, reducing bacterial overgrowth, and increasing splanchnic blood flow. Using concealed allocation, these authors randomized patients presenting to the emergency department with severe acute pancreatitis to receive either early nasoenteric tube feeding initiated within 24 hours (n = 102) or oral feeding started at 72 hours (n = 106). If the oral diet was not tolerated, tube feeding was initiated after 96 hours. The 2 groups were similar at baseline: the mean age was 65 years and 60% of the patients had evidence of systemic inflammatory response syndrome (SIRS). Analysis was by intention to treat. One third of patients in the oral group eventually required tube feeding. For the primary composite end point of death or major infection (infected pancreatic necrosis, bacteremia, or pneumonia), there was no significant difference detected between the 2 groups. When the outcomes of major infection and death were examined separately, the 2 groups again had comparable results. Finally, patients in both groups had similar rates of admission to the intensive care unit and similar need for mechanical ventilation. Given fewer-than-expected events in the control group, it is possible that the study was too small to detect a difference in the primary outcome, if such a difference exists.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
LISTEN NOW: SHM Launches a Patient Experience Committee
LISTEN NOW: Peter Pronovost, MD, PhD, Explains Hospitalists' Role in Improving the U.S. Healthcare System
LISTEN NOW: Ron Greeno Discusses Key Policy Issues Facing Hospitalists
SHM Public Policy Committee Chair Ron Greeno, MD, MHM, talks about policy issues facing hospitalist, and how "Hill Day 2015" works as an advocacy tool.
SHM Public Policy Committee Chair Ron Greeno, MD, MHM, talks about policy issues facing hospitalist, and how "Hill Day 2015" works as an advocacy tool.
SHM Public Policy Committee Chair Ron Greeno, MD, MHM, talks about policy issues facing hospitalist, and how "Hill Day 2015" works as an advocacy tool.
