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Varied times to debrillation after in-hospital cardiac arrest, and more.

Time to defibrillation varies widely among hospitals

Time to defibrillation after in-hospital cardiac arrest varies widely among hospitals, but not because of traditional factors, a recent study reports.

Researchers used the National Registry of Cardiopulmonary Resuscitation to examine how much rates of delayed defibrillation (>2 minutes) varied at U.S. hospitals and what factors were associated with such delays. Data from 7,479 adult patients who had cardiac arrest at 200 hospitals were analyzed. The study results appeared in the July 27 Archives of Internal Medicine.

Adjusted rates of delayed defibrillation among hospitals ranged from 2.4% to 50.9%. After adjustment for patient factors, hospital-level factors explained most of the difference: “We found a 46% greater odds of patients with identical covariates getting delayed defibrillation at one randomly selected hospital compared with another,” the authors wrote. However, most traditional hospital factors, such as academic status, did not affect time to defibrillation, with the exception of bed volume (odds ratios, 0.62 [95% CI, 0.48 to 0.80] for 200 to 499 beds vs. <200 beds and 0.74 [95% CI, 0.53 to 1.04] for ≥500 beds vs. <200 beds) and location of cardiac arrest (odds ratios, 1.92 [95% CI, 1.65 to 2.22] for telemetry unit vs. ICU and 1.90 [95% CI, 1.61 to 2.24] for unmonitored unit vs. ICU). Hospitals with better time to defibrillation also had better adjusted rates of survival to hospital discharge.

The authors acknowledged their study's limitations, including its observational design and its lack of information on some important hospital characteristics, such as nurse-to-patient ratio. However, they concluded that rates of defibrillation after in-hospital cardiac arrest vary widely among U.S. hospitals, but few facility characteristics were found to explain this variation. Future research, they wrote, should examine the processes used at top-performing hospitals so that they can be implemented at other institutions. The authors of an accompanying editorial called for more research, writing, “Once effective strategies have been developed and tested, individual hospitals can implement and adapt those strategies that are feasible within their local environment.”

Eligible CAD patients aren't always referred to cardiac rehab

Only slightly more than half of eligible patients with coronary artery disease (CAD) are referred to cardiac rehabilitation at hospital discharge, a recent study found.

Researchers analyzed 72,817 CAD patients in 156 hospitals from the American Heart Association's Get With the Guidelines program who had been discharged after MI, percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. They identified factors associated with cardiac rehabilitation referral at discharge and performed multivariable logistic regression to identify factors independently associated with referral. Mean patient age was 64 years; 68% of patients were men. The study was published in the Aug. 4 Journal of the American College of Cardiology.

Fifty-six percent of eligible CAD patients were referred to cardiac rehabilitation at discharge, ranging from 53% for patients admitted with MI to 58% for those admitted for PCI to 74% for those admitted for CABG. The median referral rate by hospitals was 43%, with 35% of hospitals referring fewer than 20% of eligible patients and one-third referring more than 60% of eligible patients. Patients who were older, had non-ST-segment elevation MI, and had the most comorbidities had lower odds of being referred.

Limitations of the study include the fact that hospital participation in Get With the Guidelines is voluntary, and results may not be the same in non-participating hospitals. If anything, it's more likely that the study's results reflect a “best-case scenario among hospitals with high adherence rates to core measures in general,” the authors said. Because it's associated with reductions in mortality and recurrent MI, cardiac rehabilitation after MI or revascularization is a class I indication in several national guidelines, the authors noted. It is clearly necessary to raise awareness among doctors about the benefits of referring patients to cardiac rehab, the authors added.

Hospitals with hospitalists score better on quality, care indicators

Hospitals with hospitalists perform better on quality indicators for acute myocardial infarction (AMI) and pneumonia, as well as on two dimensions of care, than hospitals without hospitalists, a recent study found.

Researchers used data from the Hospital Quality Alliance (HQA) to measure hospital-level process indicators of care for AMI, congestive heart failure (CHF) and pneumonia at 3,619 hospitals from Oct. 1, 2005 through Sept. 31, 2006. They linked these data to a second set of data on medical and surgical hospital characteristics, including whether a hospitalist program existed, from the American Hospital Association's 2005 National Survey of Hospitals. The main outcome measures were composite measurements of hospital-level quality of care for AMI, CHF and pneumonia, as well as two dimensions of care: treatment and diagnosis, and counseling and prevention. Results were reported in the Aug. 10/24 Archives of Internal Medicine.

Forty percent of the HQA hospitals had hospitalists; these facilities tended to be large, private, nonprofit teaching institutions in the southern U.S. For all three quality of care conditions, unadjusted composite scores were higher at hospitals with hospitalists than without (93% vs. 86% for AMI, 82% vs. 72% for CHF, and 75% vs. 71% for pneumonia; P<0.001 for all). Scores on treatment and diagnosis were also higher at hospitals with hospitalists (87% vs. 77%, P<0.001), as were scores on counseling and prevention (75% vs. 66%, P<0.001). In all areas except CHF, hospitals with hospitalists still scored significantly better after controlling for variables such as size, location and staffing availability.

The study was limited in that the data measured hospital-level performance, rather than matching individual patient care to whether a hospitalist provided care, the authors said. It also focused on only three diseases, while hospitalists care for many more than this, they noted. An accompanying editorial said the study contained too many confounding variables to definitively conclude that hospitalists improve quality of care, and suggested that future research focus on the best ways to structure hospitalist programs rather than trying to prove the value of hospitalists.

Resident work restrictions have not hurt outcomes in ICU

In-hospital mortality in intensive care units has decreased since restrictions on resident work hours were instituted in 2003, suggesting that the rules have not compromised patient care, a recent retrospective cohort study concluded.

The study compared mortality before and after July 1, 2003 in 104 ICUs at 40 teaching and nonteaching hospitals from July 1, 2001 to June 30, 2005. Out of a total of 230,151 adult patients admitted to the ICUs, risk-adjusted mortality improved in hospitals of all teaching levels and there were no significant differences in mortality trends between hospitals of different teaching intensities. Since the decrease was not associated with teaching status, the authors concluded that resident work-hour rules had no net positive or negative association with major outcomes. The results appeared in the September 2009 Critical Care Medicine.

The findings build upon previous research by showing that work-hour rules have not affected major outcomes in the ICU, where patients are at high risk for adverse events and sensitive to changes in staffing, the authors said. While proponents and critics of the reforms have argued, respectively, that patients would be either positively or negatively affected by the rules, these results do not provide evidence for either a dramatic improvement or decline in patient outcomes, they added. Several factors may explain the findings, including that many institutions have increased the role of nonphysician providers and/or have transferred more decision making to more senior physicians.

The authors acknowledged that the study has several limitations, including its observational nature using an existing database that could not provide specific details on ICU staffing, whether or when programs complied with the new rules, and whether there were changes in admission policies or resident case loads. The study assumes that all hospitals adhered to the regulations within two years of the implementation date when, in reality, many programs are still struggling to comply or adopted reform at different times, they added. The study also did not account for patients who died after being transferred to other facilities.

While the findings show that more humane resident work hours are possible without compromising patient care, the authors stressed that their study did not measure nonfatal medical errors or the impact of the regulations on costs or education. They concluded that further study is needed in order to understand the implications for resource utilization and to inform efforts to balance patient care with physician education and training.

Glucose monitoring devices may lead to fatal errors

Glucose testing with GDH-PQQ strips could lead to fatal errors in patients consuming nonglucose sugars, the FDA reported in a public health notification in August.

Because GDH-PQQ test strips do not distinguish between types of sugars, they may falsely indicate hyperglycemia in patients consuming products containing nonglucose sugars such as maltose, xylose and galactose. This can lead to inappropriate dosing and administration of insulin, potentially resulting in hypoglycemia, coma, or death, the FDA said. In addition, actual hypoglycemia could be missed if patients and practitioners rely only on the GDH-PQQ test result. From 1997 to 2009, the FDA has received 13 reports of deaths associated with GDH-PQQ glucose test strips where interference from maltose or other nonglucose sugars was documented.

The FDA noted that this problem does not apply to other glucose test strip methods or laboratory-based blood glucose assays. A list of recommendations to reduce the risk associated with GDH-PQQ test strips is available online.

Rxs drop for respiratory infections, rise for quinolones

Antibiotic prescription rates for acute respiratory tract infection declined between 1995-2006 in the U.S., especially among young children and for non-otitis media infections, but rates for broad-spectrum antibiotics rose sharply during the same period.

Using data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, researchers examined trends in prescribing by antibiotic indication and class. Annual acute respiratory tract infection (ARTI) visit rates fell by 17% and ARTI-associated prescriptions decreased by 36% among children younger than five years, while among those five years or older, ARTI prescriptions dropped by 18% while ARTI-related visits remained stable. The decrease in antibiotic prescriptions in children younger than five was largely related to a decrease in otitis media visit rates.

In addition, researchers reported that antibiotic prescribing for non-otitis media ARTI decreased by 41% among young children and by 24% among those older than five. While prescriptions decreased for penicillin, cephalosporin and sulfonamide/ tetracycline, ARTI-related prescriptions of azithromycin increased during the study period (ninefold among those five and under and sixfold among those older than five), and prescriptions for quinolones increased fivefold in those older than five. The results appeared in the Aug. 19 Journal of the American Medical Association.

The findings point to improvements in antibiotic prescribing practices since the mid-1990s, when the CDC and other health organizations launched initiatives promoting appropriate use of antibiotics, the authors said. Declines in ARTI visit rates could be due to physicians applying stricter diagnostic criteria for ARTI, they speculated, and parents becoming more educated about how to identify and treat mild ear infections at home.

However, the substantial rise in prescriptions for selected macrolides and quinolones is concerning, the authors said. Increased use of these antibiotics has the potential to fuel emergent antibiotic-resistant microorganisms, especially Streptococcus pneumoniae, they said, suggesting that further efforts are needed to encourage appropriate antibiotic use.