In the News

Reporting impaired colleagues, updated guidelines on spontaneous intracerebral hemorrhage, and more.

Physicians don't always report impaired or incompetent colleagues

Most physicians agree they have an ethical obligation to report impaired or incompetent colleagues, but many don't always do so, according to a recent study.

Researchers performed a survey of 2,938 physicians practicing in the fields of anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics and psychiatry. Nearly 2,000 (n =1,891) physicians responded (64.4%). Respondents were asked whether they agreed or disagreed that physicians should always report impaired or incompetent colleagues. They were also asked whether they were prepared to deal with such colleagues and whether they had been aware of and subsequently reported an impaired or incompetent colleague in the past three years. Those who reported knowing of an impaired or incompetent colleague were asked if they had ever not reported unprofessional behavior for certain reasons, such as believing someone else was handling the problem or that the physician in question would be too harshly disciplined as a result of the reporting. The survey results appeared in the July 14, 2010 Journal of the American Medical Association.

Overall, 1,120 physicians (64% of the respondents) agreed that the tenets of their profession obligated them to report impaired or incompetent colleagues. Still, only 69% (n=1,208) were prepared to deal with impaired colleagues and 64% (n=1,126) were prepared to deal with incompetent colleagues. Of the 309 physicians (17%) who personally knew an incompetent colleague, 67% (n=204) said that they had reported him or her. Physicians who were underrepresented minorities, who did not graduate from a U.S. medical school and who lived in an area where malpractice claim numbers were high were less likely to report, while those working in hospitals or medical schools rather than group or small practices were more likely to report. Physicians were most likely to cite a belief that “someone else was taking care of the problem” as the reason for failing to report. Other common reasons included believing that reporting would have no effect and fearing that it would lead to retribution.

The study results may have been affected by nonresponse bias, and physicians may have been wrong about their colleagues' job performance. However, the authors concluded that based on their survey results, self-regulation does not guarantee accurate reporting of impaired or incompetent physicians. External regulation by such bodies as professional societies should be strengthened, they suggested, and reporting systems must guarantee reporting physicians' anonymity and provide feedback once the reported problem is addressed.

Updated guidelines issued on management of spontaneous intracerebral hemorrhage

The American Heart Association and American Stroke Association recently issued updated guidelines on management of spontaneous intracerebral hemorrhage (ICH).

New recommendations or those revised from the 2007 guidelines include the following:

  • Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, respectively.
  • Patients with ICH whose international normalized ratios are elevated due to oral anticoagulants should have warfarin withheld, receive therapy to replace vitamin K-dependent factors and correct the international normalized ratio, and receive intravenous vitamin K.
  • In patients presenting with a systolic blood pressure of 150 to 220 mm Hg, acute lowering of systolic blood pressure to 140 mm Hg is probably safe.
  • Patients with cerebellar hemorrhage who have neurologic deterioration or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible.
  • No clear evidence at present indicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate.
  • Glucose should be monitored and normoglycemia is recommended.
  • After documentation of cessation of bleeding, low-dose subcutaneous low-molecular weight heparin or unfractionated heparin may be considered for VTE prophylaxis in patients with lack of mobility after 1 to 4 days from onset of ICH.
  • Patients with clinical seizures, and patients with a change in mental status who are found to have electrographic seizures on EEG, should be treated with antiepileptic drugs.
  • When stratifying a patient's risk of recurrent ICH may affect other management decisions, it is reasonable to consider the following risk factors: lobar location of the initial ICH, older age, ongoing anticoagulation, presence of the apolipoprotein E ε2 or ε4 alleles, and greater number of microbleeds on MRI.

After the acute ICH, in patients without medical contraindications, blood pressure should be well controlled, especially in those whose ICH location is typical of hypertensive vasculopathy. The complete guidelines were published in the Sept. 1, 2010 Stroke.

New guidelines on diagnosing, preventing and treating delirium

The U.K.'s National Institute for Health and Clinical Excellence (NICE) has released new guidelines on recognizing, preventing and managing delirium, based on systematic reviews of best available evidence and cost-effectiveness, an article said.

Poorly recognized, delirium affects as many as 30% of inpatients, yet it can be prevented in about one-third of at-risk patients, the article said. When patients first present to the hospital, they should be assessed for risk factors, including age 65 years and older; cognitive impairment (past or present), dementia or both; current hip fracture; and severe illness. Patients should also be observed once admitted to the hospital for any changes in the risk factors for delirium, said the guidelines, which were published online July 28, 2010 by BMJ.

Recommended interventions to prevent delirium include:

  • Ensure those at risk of delirium are cared for by people familiar to the person. Don't change staff excessively during the person's stay.
  • Avoid moving patients within and between units or rooms unless absolutely necessary.
  • Within 24 hours of admission, assess people at risk for the following clinical factors that might precipitate delirium:
  • cognitive impairment, disorientation or both;
  • dehydration, constipation or both;
  • hypoxia;
  • immobility or limited mobility;
  • infection;
  • multiple medications;
  • pain;
  • poor nutrition;
  • sensory impairment; and
  • sleep disturbance.

At-risk, admitted patients should also be assessed daily for behavioral changes or fluctuations. The changes may be reported by the patient, a relative or caregiver, and may affect cognitive function (poor concentration, slow responses, confusion); perception (for example, visual or auditory hallucinations); physical function (reduced mobility or movement, restlessness, agitation, sleep disturbance, appetite changes); and social behavior (lack of cooperation, withdrawal, alternations in mood or attitude).

If delirium indicators are present, the patient should be clinically assessed based on the criteria in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, or the short confusion assessment method (CAM), the guidelines said. For those diagnosed with delirium, identify and manage the possible underlying cause(s); reorient the person (for example, explain where the person is, who they are and what your role is); and provide reassurance. Consider involving family and friends to help with reassurance. If a person with delirium is distressed or considered a risk to self or others, use verbal and non-verbal de-escalation techniques. If needed, consider short-term haloperidol or olanzapine at the lowest appropriate dose and titrate slowly.

Nasal swabs taken during ICU stay don't improve detection of MRSA infection

Nasal swabs taken during an ICU stay didn't improve the diagnostic accuracy beyond those taken at ICU admission to detect methicillin-resistant Staphylococcus aureus (MRSA), a study found.

In a prospective cohort study, researchers obtained nasal swabs at ICU admission for 749 consecutive patients admitted to a medical ICU over seven months in 2007-2008. Nasal swabs were then taken weekly for MRSA detection by using polymerase chain reaction while the patients were monitored for development of MRSA infection, either lower respiratory tract infection (LRTI) or bloodstream infection (BSI). (LRTI and BSI were used to define MRSA infections, as they account for the majority of ICU-acquired MRSA infections.) The study was published in the October 2010 Critical Care Medicine.

In total, 1,083 patients were admitted to the ICU during the study period, of whom 69% (n=749) had a nasal swab for MRSA taken at admission. Of the 749, 21.9% (n=164) had positive nasal colonization with MRSA at the time of ICU admission, and 10.4% (n=19) converted to testing positive during their ICU stay. The occurrence of either type of MRSA infection (LRTI or BSI) was similar for patients with or without MRSA nasal colonization identified at ICU admission (27.4% vs. 22.7%; P=0.211). MRSA infection occurrence was also similar for patients with and without MRSA nasal colonization identified at any point in their ICU stay (27.9% vs. 22.4%; P=.134). The positive predictive value of MRSA nasal colonization for infections for LRTI was 17.7%; negative predictive value was 84.4%. Sensitivity was 24.2% and specificity was 78.5%. For BSI, the positive predictive value was 11% and negative predictive value was 89.7%, with 23.1% sensitivity and 78.2% specificity.

Had clinicians in the study used the results of nasal swabs alone to judge the need for antimicrobial treatment of ICU-acquired MRSA infections, 73% of patients with MRSA lower respiratory tract infections and 73% of those with MRSA bloodstream infections wouldn't have been appropriately treated at the time infection was clinically inspected and antibiotics first prescribed, the authors noted. Surveillance swabs from multiple sites—the stool, axilla, etc.—likely would have improved predictive accuracy, as has been the case with other types of infection, so the results probably reflect the use of nasal colonization as a sole factor in making treatment decisions, they said. At-risk patients shouldn't have appropriate antimicrobial therapy withheld on the basis of previous negative MRSA nasal-swab results alone, they wrote. Further, since nasal colonization isn't predictive of MRSA infection, upper airway decontamination may not be a useful preventive measure, they added.

Study limitations include that only 69% of patients had swabs taken at the time of ICU admission, which may have led to underestimating the accuracy of the initial swab. Also, if the untested patients were actually positive for MRSA but were not placed on contact isolation, they could have been a source of spread to patients whose swabs initially tested negative.