Journal watch

Recent studies about medical trainee errors, chlorhexidine intervention, and other topics.

Certain errors more common with medical trainees, study finds

Malpractice claims attributed to medical trainees are most often the results of errors in judgment, breakdowns in teamwork and lack of technical competence while providing care, a recent study reported.

Researchers used data from the Malpractice Insurers Medical Error Prevention Study to determine the involvement of trainees in medical errors. Data were available on 1,452 closed malpractice claims from five insurers. Eight hundred eighty-nine claims in four clinical categories—obstetrics, surgery, missed and delayed diagnosis and medication—were judged to have an injury associated with a medical error, and of these, medical trainees played at least a moderately important role in 240 (27%). The study, which was funded by the Agency for Healthcare Research and Quality, appeared in the Oct. 22 Archives of Internal Medicine.

Eighty-seven percent of the 240 cases involved residents, while fellows and interns were each involved in 13%. Adverse outcomes were usually serious: One-third of the errors led to significant physical injury, one-fifth led to major physical injury, and one-third resulted in death. The most common factors contributing to medical errors among trainees were errors in judgment (173 of 240 [72%]), breakdowns in teamwork (167 of 240 [70%]) and lack of technical competence (139 of 240 [58%]).

Of teamwork problems, handoff problems and lack of supervision were the most common and were more likely to be seen in trainee than in nontrainee errors (20% vs. 12% and 54% vs. 7%, respectively). Trainee errors were also more likely than nontrainee errors to involve inpatients (70% vs. 52%). Lack of technical competence among trainees was most likely to involve diagnostic decision making and monitoring the patient or the situation.

The authors acknowledged that the errors examined in their study could have had other undetected contributing factors and that causal relationships could not be determined. Also, because the events in their study occurred before 2003, they were unable to examine the effect of the Accreditation Council for Graduate Medical Education's work-hour limits on trainees' medical errors. However, they wrote, their results point to areas that should be stressed in residency training, including teamwork and communication skills, and highlight the importance of appropriate trainee supervision.

Chlorhexidine intervention reduced catheter-associated infections

A chlorhexidine-based solution worked better than povidone-iodine in controlling catheter-associated infection, according to a study in the Oct. 22 Archives of Internal Medicine.

French researchers randomly assigned patients with central venous catheters inserted in the jugular or subclavian vein to receive disinfection with a povidone-iodine solution or a chlorhexidine-based solution. Both solutions were used to disinfect skin before catheter insertion and subsequently during dressing changes.

Culture results were available for analysis from 481 of 538 randomized catheters. Patients who received the chlorhexidine solution had a 50% decrease in catheter colonization compared with those who received the povidone-iodine solution (11.6% vs. 22.2%). A trend toward lower rates of catheter-related bloodstream infection (1.7% vs. 4.2%) was also seen in the chlorhexidine group. Use of povidone-iodine solution was found to be an independent risk factor for catheter colonization, along with jugular vein insertion.

Although their trial was not blinded, the authors concluded that patients with central venous catheters who receive disinfection with a chlorhexidine-based solution are less likely to develop catheter-related infection than those for whom a povidone-iodine solution is used. They recommended that disinfection with chlorhexidine-based solution be considered as a replacement for povidone-iodine solution in this patient population.

New guidelines on ED imaging for seizure

The American Academy of Neurology has issued new guidelines on emergency department imaging in patients who present with seizure.

According to the guidelines, which were developed after a review of the literature and appeared in the Oct. 30 issue of Neurology, emergency computed tomography (CT) may be considered in adults and children with first seizure, children younger than six months and patients with AIDS. The guidelines also recommended consideration of immediate CT in patients who present with seizure in the ED and have abnormal findings on neurologic examination, a predisposing history or focal seizure onset. Evidence indicates that CT will change treatment in up to 17% of adults and 8% of children presenting with a first seizure in the ED, the guideline authors found.

None of the recommendations were level A, the strongest category, because the studies reviewed had methodologic limitations such as lack of blinding, the guideline authors wrote. However, they noted, emergency treatment of seizures is difficult to study in blinded trials. The authors recommended that future research should examine the use of magnetic resonance imaging, which may be more sensitive than CT for determining seizures' underlying causes.

Rapid treatment of TIA and minor stroke improves outcomes

Rapid treatment of transient ischemic attack (TIA) and minor stroke greatly reduces the risk of recurrent stroke, according to two recent studies.

In the first study, French researchers set up a 24-hour hospital clinic to provide more rapid evaluation of patients with suspected TIA. Referred patients with TIA symptoms underwent standard clinical assessment (neurological, arterial and cardiac imaging) within four hours of clinic admission and received treatment and comprehensive stroke prevention therapy as warranted. The researchers compared actual stroke rates within 90 days with the expected rate based on patients' ABCD2 scores. The study was released early online and appeared in the November Lancet Neurology.

From January 2003 to December 2005, 1,085 patients with suspected TIA were admitted to the hospital clinic, more than half within 24 hours of symptom onset. Of the 1,085 patients, 701 (65%) were confirmed to have TIA or minor stroke and 144 (13%) were diagnosed with possible TIA. All of the patients with confirmed or possible TIA received comprehensive stroke prevention measures; 43 (5%) underwent urgent carotid revascularization, and 44 (5%) received anticoagulants for atrial fibrillation. Almost 75% of patients seen at the clinic were discharged home on the same day, and their family physicians received discharge summaries stating the goals of stroke prevention therapy (e.g., lowered blood pressure and LDL cholesterol levels and smoking cessation). At 90 days, 1.24% of patients had had a stroke, compared with the predicted rate of 5.96%. The rate of vascular death and myocardial infarction at one year in patients with confirmed TIA or minor stroke was 1.1%.

The authors attributed their results to early neurological assessment and rapid initiation or adjustment of stroke prevention therapy. Although their trial was not randomized and recall bias may have been a factor, the authors concluded that rapid stroke assessment in a 24-hour clinic could reduce hospital length of stay and decrease recurrent stroke risk.

The second study, which was also released early online and appeared in the Oct. 20 Lancet, examined rapid assessment of TIA and minor stroke in patients referred to a stroke clinic. In phase 1 of the study, the stroke clinic was appointment-based and recommended treatment to the referring physician rather than providing it, while in phase 2, appointments were not required and treatment was begun immediately once a diagnosis was confirmed. Six hundred thirty-four patients were seen during phase 1 and 644 were seen during phase 2. Treatment was initiated much more quickly during the second phase of the study than in the first (median delay, 1 day vs. 20 days), and the risk for recurrent stroke at 90 days was much lower (2.1% vs. 10.3%). The researchers recommended additional follow-up to ascertain long-term outcome but said their results have immediate public health implications for treatment of patients with suspected TIA and minor stroke.