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Multidisciplinary teams and ICU outcomes, and more.

Multidisciplinary teams associated with improved ICU outcomes

Critically ill patients who are cared for by multidisciplinary teams have better outcomes than those who are not, according to a study.

Researchers conducted a population-based, retrospective cohort study to examine the relationship between multidisciplinary care and 30-day mortality among 107,324 medical patients at 112 acute care hospitals in Pennsylvania. Data were obtained via survey. The authors defined multidisciplinary care as “daily multidisciplinary ICU rounds consisting of the physician, nurse, and other health care professionals (eg, social worker, respiratory therapist, pharmacist).” The authors also classified the ICU staffing models as high-intensity, defined as mandatory intensivist consult or primary intensivist management, and low-intensity, defined as optional intensivist consult or no intensivist. The study results appeared in the Feb. 22 Archives of Internal Medicine.

At 30 days, the overall mortality rate was 18.3%. The authors adjusted for patient and hospital characteristics and found that multidisciplinary care was associated with statistically significantly reduced odds for death (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.76 to 0.93; P=0.001). Patients whose ICUs had high-intensity physician staffing and used multidisciplinary care teams had the lowest odds for death (OR, 0.78; CI, 0.68 to 0.89; P<0.001) compared with patients whose ICUs had low-intensity physician staffing and no multidisciplinary teams. Patients whose ICUs used low-intensity staffing and multidisciplinary teams were also at decreased odds for death (OR, 0.88; CI, 0.79 to 0.97; P=0.01). Multidisciplinary care combined with high-intensity staffing had the same mortality benefit in patients requiring mechanical ventilation, those with sepsis and those who were most severely ill.

The study was limited because it studied only medical patients and its findings cannot be generalized to surgical, cardiac or neurological patients, among other factors. However, the authors concluded that multidisciplinary care teams are beneficial in ICUs and called on clinicians, administrators and policymakers to use their results to help improve outcomes.

Costs, readmissions higher when hospitalists attend upper GI hemorrhage patients

Costs and unadjusted readmissions were higher in upper gastrointestinal hemorrhage (UGIH) patients attended by hospitalists compared to nonhospitalists, while other outcomes were the same, a study found.

In a prospective, observational trial, researchers studied 450 UGIH patients admitted to the general medicine service of six academic hospitals. Data were obtained from hospital administrative records, patient interviews and medical chart abstractions. Outcomes were in-hospital mortality and complications including recurrent bleeding, ICU transfer, decompensation, transfusion, reendoscopy and 30-day readmission. Hospital costs and length of stay (LOS) were used to measure efficiency. The study was published in the March Journal of Hospital Medicine.

Forty percent of patients were attended by hospitalists; there was no difference between groups by endoscopic diagnosis, performance of early esophagogastroduodenoscopy, Rockall risk score, or Charlson comorbidity index. Patient outcomes in the two groups weren't significantly different, except that those attended by hospitalists were more likely to receive a transfusion (74% vs. 63%; P=0.02) or to be readmitted within 30 days (7.3% vs. 3.3%; P=0.05).

Differences in transfusion rates weren't seen after multivariable adjustment, while researchers were unable to do adjusted analysis for readmissions. In unadjusted analysis, patients attended by hospitalists had higher median costs ($7,359 vs. $6,181; P<0.01), while median LOS was similar at four days. In multivariable analysis, LOS was still similar and costs were higher for hospitalist-attended patients (P<0.03).

The study findings suggest the academic hospitalist model may not have as great an impact on hospital efficiency in patient groups that require nonurgent subspeciality consultation, the authors concluded. In these patients, timing and involvement of subspecialists may influence discharge decisions, thus affecting LOS and overall costs, they said.

Updated C. difficile guidelines address changes in drug efficacy

Two professional societies have issued updated Clostridium difficile guidelines to address epidemiologic and treatment changes since guidelines were first released in 1995.

In the last 15 years, researchers have identified a more virulent strain of C. difficile and have published data on the decreased effectiveness of metronidazole in severe disease, said the update by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. The update was published in the May Infection Control and Hospital Epidemiology. Recommendations include:

  • While stool culture is the most sensitive test, it is not clinically practical. Toxin testing is most important clinically, but lacks sensitivity. A potential strategy is to employ a two-step method that uses enzyme immunoassay detection of glutamate dehydrogenase (GDH) as initial screening, and then uses the cell cytotoxicity assay or toxigenic culture as the confirmatory test for GDH-positive stool specimens. Since results seem to differ based on the GDH kit used, this is an interim recommendation.
  • Polymerase chain reaction (PCR) testing seems to be rapid, sensitive and specific, but more data are needed before it can be recommended for routine testing.
  • Avoid repeat testing during the same episode of diarrhea; it has limited value.
  • Use metronidazole for an initial episode of mild-to-moderate C. difficile infection (CDI). The dosage is 500 mg orally three times per day for 10 to 14 days.
  • For an initial episode of severe CDI, use vancomycin. The dosage is 125 mg orally four times per day for 10 to 14 days.
  • For the first recurrence of CDI, usually use the same regimen as the initial episode, though stratify by disease severity. For the second or later recurrence, use vancomycin with a tapered and/or pulse regimen. Don't use metronidazole after the first recurrence or for long-term chronic therapy, due to the potential for cumulative neurotoxicity.
  • Health care workers and visitors must use gloves and gowns on entering the room of a patient with CDI. Emphasize hand hygiene compliance and contact precautions.

Many older adults need end-of-life decisions made but lack ability

About 30% of older adults near the end of life needed decisions made about medical treatment but lacked such decision-making capacity, a new study found, and most of those with advance directives got the care they had specified.

Using data from the Health and Retirement Study, researchers studied 3,746 adults age 60 years or older who had died between 2000 and 2006 and for whom a proxy answered study questions after the patient died. Outcomes included whether the patient had completed a living will or durable power of attorney, maintained decision-making capacity, and needed decision making at the end of his or her life. Data were also collected on care preferences of subjects who completed a living will, and researchers compared these preferences with the outcomes of surrogate decision making. Results were published in the April 1 New England Journal of Medicine.

Forty-two-and-a-half percent of study patients needed decision making, and of these, 70.3% lacked the capacity to make decisions for themselves. Within this subgroup, 67.6% of patients had advance directives; 6.8% had only a living will; 21.3% had only appointed a durable power of attorney; and 39.4% had both prepared a living will and appointed a durable power of attorney. Among those patients who had completed living wills and stated preferences for or against all care possible, there was strong agreement between their preference and the care received (P<0.001). Eighty-three percent of those who requested limited care, and 97.1% of those who requested comfort care, got care consistent with these preferences. Those who requested all care possible were more likely to get it than those who didn't request it (adjusted odds ratio, 22.62; 95% CI, 4.45 to 115), but 7.1% (n=30) of those who didn't indicate an all-care preference got it anyway, and 50% (n=5) of those who wanted all care didn't receive it.

While the results suggest more than a quarter of older adults may need surrogate decision making before death, the data also indicate it's difficult to predict who will need this decision making, the authors noted. The fact that so many older adults have advance directives suggests they find them acceptable, familiar, available and valuable, they added. A causal relationship can't be inferred, but the findings suggest advance directives influence end-of-life decisions, they said. Of those patients who wanted aggressive care but didn't receive it, the decisions may have been overridden by their surrogates, or such care may not have been an option. Overall, the study suggests the health care system should ensure clinicians receive the time and reimbursement needed to help patients plan for the end of life, the authors concluded.

Diabetes drugs not restarted at discharge post-MI

Diabetic patients who are hospitalized for acute myocardial infarction (AMI) are not always restarted on their antihyperglycemic therapy upon discharge, and those not getting the drugs have a higher risk of death, a study found.

The retrospective study included about 9,000 Medicare beneficiaries who had diabetes, were discharged after hospitalization for AMI, and were taking at least one antihyperglycemic agent when admitted. The primary outcome of the study was death within a year, with a secondary outcome of rehospitalization within one year. The study was published May 1 in Circulation: Cardiovascular Quality and Outcomes.

At discharge, 86.6% of the patients were prescribed an antihyperglycemic therapy, but the other 13.4% of the studied patients were off diabetes drugs. Over the next year, the patients who didn't get the drugs had a significantly higher mortality rate (hazard ratio, 1.29; 95% CI, 1.15 to 1.45). The two groups did not show a significant difference, however, in readmission rates.

According to the study authors, the results show that abandonment of antihyperglycemic therapy in older patients with recent AMI can be problematic, despite doubts raised about the benefits of intensive glycemic control by recent studies. The authors cautioned that they weren't able to evaluate the relationship between glycemic control and mortality directly because the study used discharge medications as a surrogate marker. The study was also limited by lack of information about the reasons for discontinuation of the medications.