In the News

Guidelines on spontaneous intracerebral hemorrhage, hospital weekend services, low-risk chest pain patients, and more.

Guidelines released on management of spontaneous intracerebral hemorrhage

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

The guidelines are based on a review of the literature through August 2013, including new phase 3 trials, and updated the previous guidelines, which were published in 2010. They cover 15 sections, including:

  • emergency diagnosis and assessment of ICH and its causes;
  • hemostasis and coagulopathy;
  • blood pressure management;
  • inpatient management;
  • procedures;
  • outcome prediction;
  • prevention of recurrent ICH;
  • rehabilitation; and
  • future considerations.

ICH is a medical emergency, and the guidelines recommend that initial monitoring and management of ICH patients take place in an ICU or dedicated stroke unit with physician and nursing neuroscience acute care expertise (class I recommendation; level B evidence). Glucose should be monitored, and hyperglycemia and hypoglycemia should both be avoided (class I recommendation; level B evidence). It may be reasonable to treat fever after ICH (class IIb recommendation; level C evidence), the guideline stated.

A new recommendation in the category of seizures and antiseizure drugs stated that continuous monitoring with electroencephalography (EEG) is probably indicated in ICH patients with depressed mental status out of proportion to the degree of brain injury (class IIa recommendation; level C evidence). Two new recommendations in the category of management of medical complications state that formal screening for dysphagia should be done in all patients before oral intake is initiated to reduce pneumonia risk (class I recommendation; level B evidence) and that it is reasonable to perform systematic screening for myocardial ischemia or infarction with electrocardiogram and cardiac enzyme testing after ICH (class IIa recommendation; level C evidence).

The full guideline was published in the July Stroke.

Hospital initiative bolsters weekend services, staff and decreases length of stay

One New York medical center's intervention, which increased weekend services and staffing, successfully reduced average length of stay and increased the number of weekend discharges, according to a recent study.

In 2012, NYU Langone Medical Center implemented the 7-Day Hospital Initiative with 5 major components: 1) expanded access to diagnostic procedures on weekends; 2) expanded hospitalist coverage on the medicine service on weekends, with improved structure for patient handoffs; 3) increased care management services on weekends; 4) improved discharge processes; and 5) increased elective surgeries on weekends. The increase in weekend staffing of hospitalists occurred on July 1, 2012, when the staff number increased from 6.5 to 12.5 full-time equivalents.

The study included 57,163 hospitalizations of 38,703 unique patients admitted after Jan. 1, 2011, and discharged before Jan. 31, 2014. After the hospital implemented the intervention, average length of stay decreased by 13% and continued to decrease by 1% per month as compared to the underlying time trend. The proportion of weekend discharges increased by 12% at the time of intervention and continued to increase by 2% per month. The intervention had no impact on readmissions or mortality, the study found.

Under the new system, the weekend hospitalist was included in Friday rounds, and on weekend mornings, physicians and care managers reviewed the disposition of all patients. The results suggest that such changes in weekend care may improve hospital throughput, the study authors concluded.

However, the study was limited by 2 significant changes during the period: Hurricane Sandy (which closed the hospital for 2 months, closed the ED for the duration of the study, and significantly changed patient census) and a new electronic health record. These potential confounders exemplify the challenges of measuring an intervention in a real-world setting, the study authors noted, calling for additional studies to evaluate similar interventions in other hospitals. The study was published online May 7 in the Journal of General Internal Medicine.

Low-risk chest pain patients unlikely to have cardiac events during hospitalization

Patients who were admitted for chest pain but had negative serial biomarker results had very few adverse cardiac events during hospitalization, a study found.

Researchers included 11,230 adult patients admitted from the EDs of 3 community teaching hospitals between July 1, 2008, and June 30, 2013. All had a primary presenting symptom of chest pain, chest tightness, chest burning, or chest pressure, as well as 2 negative troponin tests. The mean patient age was 58.0 years, and 55% of the patients were women. History included hypertension in 46%, diabetes in 20%, and myocardial infarction in 13%. Results were published by JAMA Internal Medicine on May 18.

The primary outcome was a composite of life-threatening arrhythmia, inpatient ST-segment elevation myocardial infarction (STEMI), cardiac or respiratory arrest, or death during hospitalization. It occurred in 20 patients (0.18%; 95% CI, 0.11% to 0.27%). However, when patients with abnormal vital signs, electrocardiographic ischemia, left bundle-branch block, or a pacemaker rhythm were excluded, only 4 (0.06%; 95% CI, 0.02% to 0.14%) met the endpoint. Two of the events were noncardiac and 2 were possibly iatrogenic, including a periprocedural myocardial infarction and STEMI during a stress test.

The authors concluded that in chest pain patients with 2 negative biomarker tests, nonconcerning vital signs, and nonischemic electrocardiographic findings, clinically relevant adverse events during hospitalization were rare and commonly iatrogenic. They noted that other research has estimated that 1 in 164 hospitalized patients has a serious preventable adverse event from hospitalization contribute to their death, compared to only 1 in 1,817 of patients like those studied having a cardiac event during hospitalization.

“We believe that judicious follow-up is in the best interest of most such patients,” the authors wrote, noting that such follow-up may be best performed in the outpatient setting and that decision making should be shared with the patient. They added, “current recommendations to admit, observe, or perform provocative testing routinely on patients after an ED evaluation for chest pain has negative findings should be reconsidered.”

The study highlights the problem of physician decision making driving unnecessary health care use, an accompanying editorial said. Promising solutions to this issue include improvement of risk prediction tools, tools and training to educate patients about benefits and harms of treatment, and changes to reimbursement, according to the editorial.

Guidelines aim to resolve conflicts with patients and families in the ICU

A policy statement from several critical care organizations offered 4 recommendations to prevent and manage intractable disagreements about life-prolonging medical treatments for patients in intensive care.

The statement was developed by the American Thoracic Society, the American Association for Critical Care Nurses, the American College of Chest Physicians, the European Society for Intensive Care Medicine, and the Society of Critical Care Medicine. The recommendations are:

  1. 1. Institutions should implement strategies to prevent intractable treatment conflicts, such as proactive communication and early involvement of expert consultants. Most disagreements in ICUs arise not from value conflicts but from breakdowns in communication that can be resolved, the statement said, and once conflicts become intractable only “second best” options remain to resolve them.
  2. 2. The term “potentially inappropriate” should be used, rather than “futile,” when treatments have at least some chance of accomplishing the effect sought by the patient, but clinicians believe ethical considerations justify not providing them. Ethical concerns might include concerns that the treatment is highly unlikely to be successful, is extremely expensive, or is intended to achieve a goal of controversial value.

The word “inappropriate” conveys more clearly than the word “futile” or “ineffective” that a clinician's recommendation depends both on technical medical expertise and a value-laden claim, rather than strictly a technical judgment. Further, the word “potentially” signals that the judgments are preliminary, rather than final, and require review.

Conflicts that remain unresolved despite intensive communication and negotiation should be managed by fair process of conflict resolution, including having a second medical opinion, conducting an interdisciplinary hospital committee review, offer surrogates the opportunity for transfer to another institution, and allowing for an external review of decisions, such as through the legal system. When time pressures, such as a rapidly deteriorating clinical condition, prevent completing the conflict resolution process and clinicians have a high degree of certainty that the requested treatment is outside accepted practice, they should initiate a temporizing plan to allow as much of the conflict-resolution process as possible to be completed. In that case, such a plan need not include the requested treatment. The authors note that “because decisions made using this approach have fewer procedural safeguards than decisions that carry out the entire [conflict resolution] process… they likely come with a higher degree of legal uncertainty for clinicians and health care institutions.”

  1. 1. The term “futile” should be restricted to the rare situations in which surrogates request interventions that cannot accomplish their intended physiologic goal. Then, clinicians should not provide such interventions and should carefully explain the rationale for the refusal. If disagreement persists, clinicians should generally seek expert consultation to help with conflict resolution and communication.
  2. 2. The medical profession should lead public engagement efforts and advocate for policies and legislation about when life-prolonging technologies should not be used.

The statement also addresses legally proscribed and legally discretionary treatments. In response to requests for either, clinicians should carefully explain the rationale for treatment refusal and, if they have any uncertainty, seek expert consultation to confirm accurate interpretation of the rule.

The statement was published online May 15 in the American Journal of Respiratory and Critical Care Medicine.