New AHA recommendations aim to lower drug errors for heart and stroke inpatients
A scientific statement by the American Heart Association, published in the April 13 Circulation, offers recommendations for reducing medication errors in hospitalized cardiovascular and stroke patients.
Recommendations include that hospitals and health care workers:
- Obtain patients' accurate weight at admission.
- Calculate creatinine clearance at admission, and as it changes, using the Cockroft-Gault formula.
- Adjust medication dosages, and heighten surveillance for adverse medication events, in older patients, who are particularly at risk due to age-related changes in how the body metabolizes drugs.
- Standardize protocols and order forms for anticoagulants.
- Integrate nurses and pharmacists into cardiovascular care teams in emergency departments, ICUs and other inpatient units to improve communication and medication safety.
- In the ED and inpatient units, use computerized order entry, medication bar-coding technology and smart infusion pumps.
- Educate staff about “high alert” medications (especially anticoagulants), safe administration techniques, medication reconciliation procedures, look-alike and sound-alike medications, and automated dispensing devices.
- Create a safety culture of no-fault error reporting and interdisciplinary quality improvement processes to reduce the frequency and effects of medication errors.
“Cardiovascular medications are the most common drug class associated with medication errors, and cardiovascular patients remain at high risk in the acute hospital phase, even with the current safety strategies,” said Andrew D. Michaels, MD, chair of the statement's writing committee, in a press release. “There are areas that need improvement, and that is what we focused on in the statement.”
Updated practice guidelines for catheter-associated UTIs
Updated clinical practice guidelines for diagnosing, preventing and treating catheter-associated urinary tract infections (CA-UTIs) were released by the Infectious Diseases Society of America (IDSA).
The guidelines, prepared by an IDSA expert panel, comprise diagnostic criteria, as well as strategies to reduce CA-UTI risk and manage patients with catheter-associated asymptomatic bacteriuria or symptomatic UTI. They also address strategies that haven't been found to reduce CA-UTIs. The guidelines are meant to be used by all physicians involved with direct patient care, especially in-hospital and long-term facility care. Recommendation strength is graded A, B and C (good, moderate and poor), and quality of evidence is I, II and III, with I being the strongest. The guidelines, published in the March 1 Clinical Infectious Diseases, include the following:
- Indwelling catheters should be removed as soon as they are no longer required to reduce the risk of CA-bacteriuria (A-I recommendation) and CA-UTI (A-II).
- In patients with indwelling urethral, indwelling suprapubic, or intermittent catheterization, CA-UTI is defined by the presence of symptoms or signs compatible with UTI with no other identified source, along with at least 103 cfu/mL of at least one bacterial species in a single catheter urine specimen, or in a midstream voided urine specimen from a patient whose catheter has been removed within the previous 48 hours (A-III).
- In patients with indwelling urethral, indwelling suprapubic, or intermittent catheterization, catheter-associated asymptomatic bacteriuria is defined by the presence of 105 cfu/mL of one bacterial species in a single catheter urine specimen in a patient without symptoms compatible with UTI (A-III).
- Signs and symptoms compatible with CA-UTI include new onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain; costovertebral angle tenderness; acute hematuria; and pelvic discomfort. Dysuria, urgent or frequent urination, or suprapubic pain or tenderness are suggestive of CA-UTI in those whose catheters have been removed (A-III).
- In the catheterized patient, pyuria is not diagnostic of CA-bacteriuria or CA-UTI (A-II). To limit unnecessary catheterization, indwelling catheters shouldn't be used to manage urinary incontinence, and should require a physician's order in the chart before placement (A-III).
- Systemic antimicrobial prophylaxis shouldn't be routinely used in patients with short-term (A-III) or long-term (A-II) catheterization—including patients who undergo surgical procedures—for the purpose of reducing CA-bacteriuria or CA-UTI.
- Prophylactic antimicrobials shouldn't be administered routinely to patients at the time of catheter placement to reduce CA-UTI (A-I) or at the time of catheter removal (B-I) or replacement (A-III) to reduce CA-bacteriuria.
- Seven days is the recommended duration of antimicrobial treatment for patients with CA-UTI who have prompt resolution of symptoms (A-III). Ten to 14 days of treatment is recommended for patients with a delayed response (A-III), whether the patient stays catheterized or not.
Report assesses health in every U.S. county
A report from the Robert Wood Johnson Foundation ranks the health of every county in the United States.
The counties are ranked within their states based on the rate of people dying before age 75, the percentage of people reporting fair or poor health, the number of days people reported being in poor physical or mental health, and the rate of low-weight births. The research also gathered data on a number of factors that could affect health, including smoking, obesity, binge drinking, access to primary care, high school graduation, motor vehicle accidents, violent crime, air pollution, liquor store density, unemployment and the number of children living in poverty.
The study found that healthier counties tended to have more residents who were educated and employed, with access to health care, healthy food and recreational facilities. Suburban and urban counties were also more likely to be healthy than rural counties, reported the Feb. 17 BusinessWeek. The research found significant disparities, even among neighboring counties, with unhealthy counties having double or triple the rates of premature death compared to the healthier counties.
The report is intended to mobilize community leaders to take action to make their counties healthier, according to a press release. A previous similar project in Kansas, for example, motivated efforts to improve urban residents' access to healthy food shopping. The county-by-county data are available online.
Proposed revisions for DSM-5 released
The American Psychiatric Association released proposed diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The revisions were developed by 13 work groups and include changes such as:
- Elimination of the diagnostic category of substance dependence. Both substance abuse and dependence will fall under a new category of “addiction and related disorders.”
- New suicide scales, which include research-based criteria, to help identify individuals most at risk.
- A new category of “behavioral addictions,” in which gambling will be the only disorder. Internet addiction was considered for this category, but found to be insufficiently researched.
- A single category of “autism spectrum disorders” to include autistic disorder, Asperger's disorder, childhood disintegrative disorder and pervasive developmental disorder.
- A change from the term “mental retardation” to “intellectual disability.”
- A new “risk syndromes” category to identify earlier stages of mental disorders including dementia.
- Changes in definitions of some eating disorders to emphasize development in adults.
- Addition of “dimensional assessments” to diagnostic evaluations to take into account the severity of symptoms and cross-cutting symptoms (such as insomnia or anxiety) that occur across different diagnoses.
The new criteria will undergo review and refinement, including field trials, over the next two years. The changes can be viewed at the DSM-5 Web site. The final DSM-5 is expected to be released in May 2013. The last edition of the DSM was published in 1994.
Lower pay drives doctors to cut their hours
Lower reimbursement in the past decade has been linked to doctors cutting their hours from a mean of 55 hours per week to 51, the equivalent of losing 36,000 physicians a year.
Researchers conducted a retrospective analysis of trends in hours worked among U.S. physicians using Census Bureau survey information between 1976 and 2008. (Researchers and the U.S. Department of Labor use the same data to calculate employment trends among many professions.) They reported results in the Feb. 24 Journal of the American Medical Association.
Average physician reimbursement fell nationwide by 25% between 1995 and 2006 after adjusting for inflation. This is the same decade in which physicians began to cut back their hours, after having stable hours-per-workweek averages for the previous two decades.
Mean hours worked per week decreased by 7.2% between 1996 and 2008 among all physicians (n=116,733; 54.9 hours per week in 1996-1998 to 51.0 hours per week in 2006-2008; 95% CI, 5.3%-9%; P<0.001). When researchers excluded residents, whose hours decreased due to duty hour limits in 2003, physician hours decreased by 5.7% (95% CI, 3.8%-7.7%; P<0.001).
Mean hours worked by nonresident physicians were strongly associated with the fee index (correlation=0.965, P<0.001) and even more strongly associated with the fee index from the prior year (correlation=0.969, P<0.001).
The decrease in hours was largest for nonresident physicians younger than 45 years (7.4%; 95% CI, 4.7%-10.2%; P<0.001) and those working outside of the hospital (6.4%; 95% CI, 4.1%-8.7%; P<0.001). The decrease was smallest for those 45 years or older (3.7%; 95% CI, 1%-6.5%; P=0.008) and working in the hospital (4%; 95% CI, 0.4%-7.6%; P=0.03).
A 5.7% decrease in hours out of a workforce of approximately 630,000 physicians in 2007 equals a loss of approximately 36,000 doctors. The authors wrote, “This trend toward lower hours, if it continues, will make expanding or maintaining current levels of physician supply more difficult,” although more medical schools or international medical graduates could mitigate the problem, they suggested.