In The News

Mixing alcohol with opioids and benzodiazepines, postdischarge efforts and readmissions, and more.

One-fifth of clinicians are unaware of patients' central venous catheters

More than 20% of clinicians interviewed for a study were unaware that their patients currently had a central venous catheter in place, a recent study found.

Researchers conducted in-person interviews with 990 hospitalized patients and 1,881 clinicians between April 2012 and September 2013 at 3 U.S. academic medical centers. Clinicians included interns, residents, nurse practitioners, physician assistants, and attending physicians who had provided care to a patient for at least 24 hours. At each site, patients and clinicians were randomly selected from general medicine teaching, hospitalist-only, and subspecialty services that often use central venous catheters (CVCs). Patients were interviewed and examined for presence of a CVC (either a peripherally inserted central catheter [PICC] or triple-lumen catheter). Clinicians were interviewed about knowledge of their patients' CVCs after team rounds to ensure they had seen their patients that day.

The overall prevalence of CVCs was 21.1%, of which 60.3% were PICCs. Twenty-one percent of clinicians interviewed were unaware of the presence of a CVC, and unawareness was greatest among patients with PICCs, with 25% of clinicians being unaware of PICC presence. Teaching attendings and hospitalists were more frequently unaware of the presence of CVCs than interns and residents (25.8% and 30.5%, respectively, vs. 16.4%). Critical care doctors were more likely to be aware of CVC presence than general medicine physicians (12.6% vs. 26.2%; P=0.003). Results were published online October 21, 2014, by Annals of Internal Medicine.

Given recent evidence of problems associated with the use of CVCs and suggestions that early removal is favorable to waiting, the current findings have important patient safety and policy implications, the authors wrote. “Early removal of CVCs requires knowledge of their presence,” they said. Study limitations include that the researchers didn't link awareness of CVCs to adverse outcomes, and they didn't collect data such as the patient's indication for CVC, the duration of use, or the patient load of the clinician.

Mixing alcohol with opioids, benzodiazepines sending users to emergency departments

Nearly one-fifth of opioid abuse-related ED visits and more than one-fourth of benzodiazepine abuse-related ED visits involved alcohol, a study found.

To estimate national ED visits, researchers conducted a stratified, simple random sample of 237 nonfederal, short-stay, general hospitals that operated 24-hour EDs and that treated patients who had visits that involved alcohol and opioids or alcohol and benzodiazepines, whether alone or in combination with other drugs. ED visits involving more than 1 type of drug were counted in multiple categories. Results appeared in the Oct. 10, 2014, MMWR.

There were 438,718 ED visits related to opioid abuse and 408,021 ED visits related to benzodiazepine abuse, alone or in combination with other drugs, in 2010. Of the opioid ED visits, an estimated 81,365 (18.5%) involved alcohol; of the benzodiazepine ED visits, 111,165 (27.2%) involved alcohol.

Of the 3,883 opioid deaths in 2010, 860 (22.1%) involved alcohol. For benzodiazepines, 324 (21.4%) of the 1,512 deaths involved alcohol. Among single-drug class deaths, 393 (26.1%) opioid and 44 (72.1%) benzodiazepine deaths involved alcohol. Opioids stronger than hydrocodone, such as fentanyl, methadone, and hydromorphone, tended to have less alcohol involvement for both ED visits and deaths.

ED visits that involved opioids and alcohol were highest among patients ages 30 to 44 years (20.6%) and 45 to 54 years (20.0%). For benzodiazepine ED visits, the percentage was highest among patients ages 45 to 54 years (31.1%). Among opioid deaths, patients ages 40 to 49 years (25.2%) and 50 to 59 years (25.3%) had the highest percentage of alcohol involvement. For benzodiazepine-related deaths, the highest percentage (27.7%) was among persons aged ≥60 years.

ED visits involving alcohol and opioids were significantly more common among men than women: 22.9% (95% CI, 18.7% to 27.7%) versus 13.5% (95% CI, 11.1% to 16.4%). The same was true for ED visits involving alcohol and benzodiazepines: 30.6% (95% CI, 26.7% to 34.8%) for men compared to 24.1% (95% CI, 19.6% to 29.2%) for women. Researchers noted that men report higher prevalence, frequency, and intensity of binge drinking compared with women, which might have contributed to the higher percentage of alcohol involvement in ED visits among men.

That one-fifth of opioid drug abuse-related ED visits and drug-related deaths involve alcohol suggests the need for stronger prevention measures, the authors wrote.

“Interventions such as combined prevention programs that target alcohol and prescription drug abuse, systematic provider and patient education, and integration of screening and intervention services into the primary care health system to enable early identification of problematic alcohol and drug use might reduce the number of ED visits and deaths related to drug abuse and alcohol,” they wrote.

Postdischarge efforts fail to reduce readmissions

Two separate projects to reduce patients' hospital readmissions within 30 days of discharge by providing more postdischarge support recently reported negative results.

In the first study, researchers at a safety net hospital in Northern California randomized 700 low-income patients age 55 years and older who were being discharged in the community to either usual care or an intervention. The intervention included in-hospital, individual, self-management education by a registered nurse speaking the patient's language (English, Spanish, or Chinese) with postdischarge telephone follow-up by a nurse practitioner. Results were published in the Oct. 7, 2014, Annals of Internal Medicine.

The intervention didn't reduce the combined outcome of ED visits and readmissions within 30, 90, or 180 days after discharge. There was a trend toward more ED visits in the intervention group, although the difference was not statistically significant. The study may have been limited by the fact that the hospital's patients already had good access to primary care and relatively low readmission rates (15%) or that the study nurses were not integrated with the patients' other clinicians. The project was an adaptation of an intervention that had worked successfully elsewhere, so the negative findings “should give pause to hospitals adopting interventions shown to work in dissimilar populations and settings without evaluating their effect,” the study authors concluded.

The author of an accompanying editorial noted that conducting an improvement project as a randomized, controlled trial prevents researchers from changing any parts of the intervention that aren't effective, and he suggested that concentrating on high-risk patients, providing different educational materials to health-illiterate patients (such as pictographic formats), and involving patients' families could have led to better results.

In the second study, 1,923 adult patients in Toronto who were seen as high risk for readmission were randomized to usual care or what the study called a “virtual ward” intervention. The intervention included several weeks of postdischarge care coordination and direct care (via telephone, home, and clinic visits) by an interdisciplinary team. Outcomes were readmission, death, ED visits, or nursing home admission within 30 days, 90 days, 6 months, and 1 year. Results were published in the Oct. 1, 2014, Journal of the American Medical Association.

There were no significant differences between the groups on any of the outcomes, although the intervention appeared to be associated with a small benefit at 30 days. Based on the results, the researchers concluded the intervention is highly unlikely to be an efficient use of health care resources. They noted that their effort was limited by a lack of integration and communication between the study personnel and the patients' outpatient and inpatient clinicians. It is possible that the model could work in a more integrated system, they noted. An accompanying editorial said that the data are useful for developing new approaches and that elements of this model could be included in future readmission prevention efforts.

Guideline released on management of non-ST-elevation acute coronary syndrome

The American Heart Association (AHA) and the American College of Cardiology (ACC) released a “2014 Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes” (NSTE-ACS) in late September.

The guideline was based on a review of evidence published through October 2012, as well as selected references published through April 2014. It revises the 2007 American College of Cardiology Foundation/AHA guideline for management of patients with unstable angina and non-ST-elevation myocardial infarction (NSTEMI), as well as the 2012 focused update.

The guideline recommends that patients with suspected ACS should be risk-stratified according to the likelihood of ACS and adverse outcomes to decide on the need for hospitalization and assist in the selection of treatment options (Class I recommendation; B evidence). Regarding discharge from the ED or chest pain unit, the guideline made these Class IIa recommendations:

  • It is reasonable to observe patients with symptoms consistent with ACS without objective evidence of myocardial ischemia (nonischemic initial electrocardiogram and normal cardiac troponin) in a chest pain unit or telemetry unit with serial ECGs and cardiac troponin at 3- to 6-hour intervals (B evidence).
  • It is reasonable for patients with possible ACS who have normal serial ECGs and cardiac troponins to have a treadmill ECG, stress myocardial perfusion imaging, or stress echocardiography before discharge or within 72 hours after discharge (B evidence).
  • In patients with possible ACS and a normal ECG, normal cardiac troponins, and no history of coronary artery disease (CAD), it is reasonable to initially perform (without serial ECGs and troponins) coronary CT angiography to assess coronary artery anatomy (A evidence) or rest myocardial perfusion imaging with a technetium-99m radiopharmaceutical to exclude myocardial ischemia (B evidence).

After hospital admission, supplemental oxygen should be administered to patients with NSTE-ACS who have arterial oxygen saturation less than 90%, respiratory distress, or other high-risk features of hypoxemia, the guideline said (Class I recommendation; C evidence). Nitroglycerin should be administered sublingually every 5 minutes for up to 3 doses for continuing ischemic pain, and need for IV nitroglycerin should then be assessed if not contraindicated (Class I recommendation; C evidence); IV nitroglycerin should be administered for persistent ischemia, heart failure, or hypertension (Class I recommendation, B evidence). Nitrates are contraindicated in patients who have recently taken a phosphodiesterase inhibitor (Class III recommendation: harm, B evidence). Any NSAIDs besides aspirin should not be started and should be discontinued during hospitalization for NSTE-ACS because of an associated increased risk for major adverse cardiovascular events, the guideline said (Class III recommendation: harm; B evidence).

During early hospitalization, oral beta-blockers should be initiated within the first 24 hours in patients without heart failure, low-output state, risk for cardiogenic shock, or other contraindication, the guideline said (class I recommendation; A evidence). It recommended sustained-release metoprolol succinate, carvedilol, or bisoprolol for beta-blocker therapy with concomitant NSTE-ACS, stabilized heart failure, and reduced systolic function (class I recommendation; C evidence). Initial therapy with nondihydropyridine calcium-channel blockers should be administered in patients with recurrent ischemia and contraindications to beta-blockers in the absence of left ventricular dysfunction, increased risk for cardiogenic shock, PR interval greater than 24 seconds, or second- or third-degree atrioventricular block without a cardiac pacemaker, the guideline said (class I recommendation; B evidence).