In the News

Guidelines for determining brain death, and more.

New guidelines and checklist on determining brain death

The American Academy of Neurology has issued updated guidelines for determining brain death in adults and a related checklist.

The guidelines, updated from 1995, take into account recent studies on clinical determination of brain death. They stipulate three signs that a person's brain has stopped functioning: the person is comatose and the cause of the coma is known; all brainstem reflexes have permanently stopped working; and breathing has permanently stopped such that a ventilator must be used to keep the body functioning. They also review the best way to demonstrate absence of breathing, and conclude that laboratory tests such as electroencephalogram (EEG) or cerebral flow studies are not needed for a diagnosis, although they can be used when uncertainty exists with the neurologic exam or when the apnea test cannot be performed. A summary statement of the guidelines was published in the June 8 Neurology . A full copy of the guidelines update is available via the American Academy of Neurology Web site.

The guidelines note that complex-spontaneous motor movements and false-positive triggering of a ventilator can occur in brain-dead patients. Also, there isn't enough evidence to determine the minimally acceptable observation period for ensuring neurologic function has irreversibly stopped, nor is there enough evidence to determine if newer ancillary tests confirm the whole brain has stopped functioning.

“The brain death diagnosis can be made only after a comprehensive clinical evaluation and often involves more than 25 separate assessments,” said lead guideline author Eelco Wijdicks, FACP, from the Mayo Clinic in Rochester, Minn., in a press release. “The new guideline includes a checklist that will help doctors with this diagnosis.”

Hospitals improving PCI, MI outcomes

Hospitals across the country are seeing improvements in caring for patients experiencing myocardial infarction (MI) or undergoing percutaneous coronary intervention (PCI), according to registry data.

The American College of Cardiology Foundation's National Cardiovascular Data Registry (NCDR) involves more than 2,400 hospitals and more than 10.6 million patient records. A full analysis appeared in the July 20, 2010 Journal of the American College of Cardiology.

An MI study group consisted of nearly 132,000 patients treated for a heart attack at approximately 250 participating hospitals from January 2007 through June 2009. The data analysis showed significant improvements in several key aspects of heart attack care, including:

  • an increase from 90.8% to 93.8% in the use of treatments to restore blood flow to the heart in patients with ST-elevated MI (STEMI),
  • an increase from 64.5% to 88% in the number of patients with STEMI heart attacks treated with PCI within 90 minutes of arriving at the hospital, a key quality benchmark,
  • an improvement from 89.6% to 92.3% in overall performance scores that measure timeliness and appropriateness of therapy for STEMI heart attacks,
  • an improvement in achieving correct dosing of several types of blood thinners among non-STEMI patients,
  • a reduction from 6.2% to 5.5% in risk-adjusted hospital death rates among STEMI patients and from 4.3% to 3.9% among NSTEMI patients, and
  • an improvement in prescribing guideline-recommended medications, including aspirin, clopidogrel, statins, beta-blockers and angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, as well as in counseling patients to stop smoking and referring patients to cardiac rehabilitation.

A PCI study group consisted of more than 1.7 million patients who'd underwent a procedure from January 2005 through June 2009. During that time, participating hospitals grew from 436 to 959. The data analysis revealed:

  • an increase in procedural complexity, including treatment of significantly more patients with challenging type C lesions (which include diffuse, tortuous, and sharply angulated lesions),
  • a reduction in complications related to bleeding or injury to the arteries used for passing tubes to the heart,
  • changes in the use of medications designed to prevent unwanted blood clots, reflecting the results of recent clinical trials and recommendations from new clinical practice guidelines, and
  • a reduction in the overall use of drug-eluting stents, partially balanced by greater use of new types of drug-eluting stents.

The analysis also highlights specific areas in need of improvement and identifies targets for future research, particularly those aimed at reducing the bleeding risk associated with even the best therapies.

Follow-up instructions don't cut readmissions for general inpatients

Providing detailed instructions for follow-up appointments to general medicine patients at discharge doesn't appear to reduce hospital readmissions or mortality rates 30 or 180 days later, a study found.

Researchers retrospectively reviewed all hospital discharge records for general internal medicine inpatients dismissed from the Mayo Clinic in Rochester, Minn. in 2006. Patients discharged to home with skilled nursing services weren't included, and neither were patients discharged to a long-term care facility or hospice, or transferred to another inpatient service. Those discharged to home with home health services were included. To be considered complete, appointment documentation had to include a specific date and time, and a location or physician. Results were published in the June 14 Archives of Internal Medicine.

Of the 4,989 patient records reviewed, 60.9% (n=3,037) had detailed follow-up appointment instructions. Appointments were scheduled a median of six days after discharge, though they ranged from the same day as discharge to nine months later. The mean age of patients with follow-up appointments was 62.3 years vs. 61 years without (P=0.02). Those with appointments also had a longer length of stay (3.3 days vs. 2.7 days; P<0.001).

There were no significant associations between having a scheduled follow-up appointment at discharge and related hospital readmission or emergency department visits, within 30 days. There were also no associations between appointments and mortality at 30 days. When data were adjusted for factors including age, sex and illness severity, however, patients with appointments were more likely than those without to have a readmission or an emergency department visit at 180 days after discharge (hazard ratio=1.10; P=0.03), though they weren't more likely to die. Patients with a longer span between discharge and scheduled appointments were less likely to be readmitted within 30 days. For patients with appointments scheduled within seven days of discharge, no significant relationship was seen with any of the 30-day outcomes.

The results raise doubt about whether using documented follow-up appointments is appropriate for gauging a hospital's efforts to reduce readmissions, as the Centers for Medicare and Medicaid Services proposes, the authors said. Focusing on documentation doesn't guarantee patients will actually show up for the appointments, they noted. Further, this study found most readmissions were unrelated to the original admission, which “calls into question the concept of using readmissions as a quality indicator for the original hospitalization,” they noted.

Early follow-up reduces heart failure readmissions

A comparison of hospitals found that having a follow-up appointment with a physician within a week of being discharged from a hospital with a diagnosis of heart failure appears to reduce a patient's risk of readmission.

The observational analysis used data from the OPTIMIZE-HF and Get with the Guidelines programs to compare how many of the hospitals' heart failure patients saw a physician within a week of leaving the hospital.

The study population included more than 30,000 patients treated at 225 hospitals between 2003 and 2006. The hospitals were divided into quartiles based on follow-up rates; those results were then compared with rates of readmission within 30 days. To control for individual patient factors that might confound the association between follow up and outcomes, the authors examined the association between hospital patterns of early follow up and patient-level outcomes. Results were published in the May 5 Journal of the American Medical Association.

Overall, more than 20% of the patients were readmitted within the month. Most patients also didn't have a follow-up appointment within a week; the median percentage across the hospitals was only 38.3%. In the quartile of hospitals with the worst follow-up rates, the readmission rate was 23.3% in 30 days, compared to just under 21% in the other three quartiles.

The study also found that most patients had their follow-up appointment with a general internist; less than 10% saw a cardiologist within a week. The vast majority of patients (94%) did have an outpatient appointment scheduled while they were in the hospital, although information on the date for the follow-up visit was not available.

The findings highlight the need for improved coordination of care between inpatient and outpatient settings, the study authors concluded. They noted that the narrowing of the scope of medical practice makes this coordination more difficult, but they suggested the models of care using nurse practitioners or physician assistants could improve access to timely follow-up care.

ED visits up for nonmedical use of opioids, benzodiazepines

Emergency department visits for nonmedical opioid use rose 111% between 2004 and 2008, according to the Centers for Disease Control and Prevention (CDC).

Oxycodone, hydrocodone and methadone were the opioids associated with the greatest number of emergency department (ED) visits in the five-year period ending in 2008, according to the CDC's June 18 Morbidity and Mortality Weekly Report(MMWR). There was also an estimated 89% increase in ED visits involving nonmedical use of benzodiazepines, said the report, which is based on data submitted by 231 hospitals. Approximately one in four patients who visited the ED for nonmedical opioid or benzodiazepine use was admitted, it said.

For individual drugs, the estimated increases in ED visits for nonmedical use between 2004 and 2008 were:

  • oxycodone: 152% increase (P<0.001)
  • alprazolam: 125% increase (P=0.01)
  • clonazepam: 72% increase (P<0.001)
  • diazepam: 70% increase (P=0.02)
  • lorazepam: 107% increase (P=0.006)
  • zolpidem: 121% increase (P=0.002)

Based on this new data, peak visit rates for both opioids and benzodiazepines appear to have shifted into the 21- to 24-year and 25- to 29-year age groups by 2008, and away from the 30- to 34-year and 35- to 44-year age groups, the report said. As late as 2006, the peak mortality rate for fatal drug overdoses involving opioid analgesics had been in the 35- to 54-year age group.