In the News

Unnecessary telemetry, CAP rates and causes, sepsis and acute kidney injury, and more.

Education reduced unnecessary telemetry and costs

An educational intervention reduced use of telemetry and associated costs in a teaching hospital, according to a recent study.

The intervention included 10 teaching hospitalists at a large academic center. They taught their trainees an educational module on telemetry usage, including appropriate use guidelines and information about the cost of telemetry. The hospitalists were also encouraged (by e-mails and meeting reminders) to discuss need for telemetry on teaching rounds. They received data on past telemetry usage and a financial incentive—a $2,000 bonus if the group reduced telemetry bed use.

Hospitalists' patients' length of stay in telemetry beds decreased significantly between the pre-intervention period (January to December 2012) and the intervention period (January to August 2013): 2.75 days vs. 2.13 days (P=0.005). The cost of telemetry bed utilization also dropped, by 22.5%. A comparison group of nonhospitalists' patients showed no such changes. The reduction in telemetry length of stay continued during an extension period of the study (September 2014 to March 2015), during which it was 1.93 days. Researchers also tested the trainees before and after on their understanding of the indications and costs of telemetry and found significant improvements in their knowledge regarding the most and least cost-saving ways to safely care for patients.

The results show that a multipronged, hospitalist-driven intervention could reduce the length of stay and costs associated with telemetry, the study authors concluded. The study was limited by being at a single center and involving multiple components, the effects of which cannot be separated, but all of the components are easily transferrable to other institutions.

“Our study also revealed that nearly half of the participants were not aware of the criteria for appropriate utilization of telemetry before our intervention,” the authors wrote. They noted that reducing inappropriate use not only saves costs and resources but avoids the potential negative effects of telemetry on patients' experience, including physical restriction and disruptive alarms. The study was published in the September Journal of Hospital Medicine.

Rates and causes of community-acquired pneumonia analyzed

The pathogens causing adults to be hospitalized for pneumonia are varied and often unidentifiable, according to a recent analysis by the CDC.

The surveillance study included hospitalizations for community-acquired pneumonia in adults 18 years or older at 5 hospitals in Chicago and Nashville between January 2010 and June 2012. Patients with recent hospitalization or severe immunosuppression were excluded. Blood, urine, and respiratory specimens were used to identify pathogens. Results were published in the July 30 New England Journal of Medicine.

The study included 2,259 patients who had radiographic evidence of pneumonia and specimens available for both bacterial and viral testing. In only 38% of these cases was a pathogen detected: 23% viral, 11% bacterial, 3% both, and in 1% a fungal or mycobacterial pathogen. The most common pathogens were human rhinovirus (9%), influenza virus (6%), and Streptococcus pneumoniae (5%). For each pathogen, incidence increased with age, and overall pneumonia became more common as patients got older, from an overall incidence of 24.8 per 10,000 adults (95% CI, 23.5 to 26.1), to 63.0 per 10,000 in those 65 to 79 years and 164.3 per 10,000 in those 80 years and over.

The observed incidence rate of pneumonia is similar to that reported in a 1991 analysis, the study authors reported. Despite advances in testing, pathogens were detected in the minority of cases, they noted, calling for further development of rapid diagnostic tests. The finding that influenza was the most commonly identified pathogen shows the need for greater uptake of the flu vaccine, the authors said. Since pneumonia vaccination recommendations have changed since the study period, this data could serve as a baseline for future research into the effectiveness of the 13-valent pneumonia vaccine.

The relatively low rates of certain pathogens, including Enterobacteriaceae (1%) and other gram-negative bacteria, was likely due to the exclusion of patients with risk factors such as recent hospitalizations, in accordance with the study's focus on community-acquired pneumonia, the authors noted. Streptococcus pneumoniae, Staphylococcal aureus, and Enterobacteriaceae were significantly more common in ICU patients, the researchers noted.

Readmissions common with severe sepsis and mild or moderate AKI, study finds

A third of patients with severe sepsis or septic shock were readmitted within 30 days, and having mild-to-moderate acute kidney injury (AKI) increased that risk, a recent study found.

Researchers conducted a single-center retrospective cohort study of 1,697 patients who were hospitalized with culture-positive severe sepsis or septic shock and survived to discharge. Thirty-two percent of these patients were readmitted to the hospital within 30 days. Readmitted patients had higher median Charlson scores (5 vs. 4; P<0.001) and were more likely to have evidence of health care-associated sepsis (94.2% vs. 90.2%; P=0.014).

Patients were more likely to be readmitted in 30 days if they had mild-to-moderate AKI, as measured by the RIFLE (Risk, Injury, Failure, Loss, End-stage) criteria (odds ratio [OR] with RIFLE: Injury or RIFLE: Failure, 1.95; 95% CI, 1.30 to 2.93). Very mild or severe AKI was not associated with readmission risk, and median APACHE II scores were similar between patients who were and were not readmitted. Readmission was more likely in patients with extended spectrum beta-lactamase or Bacteroides organisms causing their sepsis and less likely if urine was the source of sepsis or Escherichia coli was the causative organism. The results were published by the Journal of Hospital Medicine on July 20.

The study shows that survivors of culture-positive severe sepsis or septic shock have a high rate of 30-day readmission, and thus institutions that treat many such patients could risk financial penalties for readmission, the study authors concluded. The observed association with AKI may suggest the need for more aggressive efforts to prevent this complication, they advised, noting that other identified risk factors for readmission weren't as modifiable. The study was limited by its single-center design and may not apply to dissimilar institutions or patients without a positive blood culture, the authors said.

Hospitals often overestimate performance of timely tPA delivery for stroke, study finds

A recent study of nearly 150 hospitals found that lower-performing hospitals overestimated their performance administering intravenous tissue plasminogen activator (tPA) to ischemic stroke patients within 1 hour of arrival.

Between January and July 2011, researchers conducted telephone surveys of staff (85% nursing staff) at 141 hospitals, which were all part of AHA's Get With the Guidelines registry for stroke. The study included a total of 48,201 stroke patients. They asked staff to rank their hospital as a low, below-average, average, above-average, or top institution in terms of their relative performance on a national level in delivering tPA.

Among the 92 low- and middle-performing hospitals, 56 (60.9%) overestimated their performance on the speed of their stroke treatment, according to the study, published online July 22 by the Journal of the American Heart Association. In the study, 85% of low-performing hospitals overestimated their performance, and almost 5% believed their performance to be “superior” on a national level.

Institutions that overestimated tended to have lower annual volumes of tPA administration (median, 8.4 patients [25th to 75th percentile, 5.9 to 11.8] vs. 10.2 patients [25th to 75th percentile, 8.2 to 17.3]; P=0.047). Overestimating hospitals also had smaller percentages of eligible patients receiving tPA (84.7% vs. 89.8%; P=0.008) and smaller percentages of tPA delivery in an hour or less among treated patients (10.6% vs. 16.6%; P=0.002).

The researchers found that sites were less likely to overestimate performance for every 10-case increase in annual tPA volume (odds ratio [OR], 0.31; 95% CI, 0.10 to 0.94) and for every 10-percentage-point increase in the percentage of tPA delivery within 60 minutes of arrival (OR, 0.59; 95% CI, 0.36 to 0.96).

“Overestimation of the quality of care that an institution provides may perpetuate suboptimal performance, whereas accurate measurements of current performance and realistic comparison to other more successful sites might provide the needed motivation to fuel quality improvement,” the study authors wrote. They added that further research is needed to pinpoint the reasons for this misperception in performance.

The researchers also acknowledged limitations of the study, such as how it included only hospitals participating in the voluntary Get With the Guidelines registry for stroke. The accuracy of perception of quantitative performance might not be applicable to non-participating hospitals, the authors noted.

Guidelines update treatments for idiopathic pulmonary fibrosis

Updated guidelines offered some changes in standards of care for idiopathic pulmonary fibrosis (IPF).

The update from 2011 guidelines was drafted by the American Thoracic Society, European Respiratory Society, Japanese Respiratory Society, and Latin American Thoracic Association. Results were published July 15 by the American Journal of Respiratory and Critical Care Medicine.

The following recommendations are new or revised from the previous guideline:

  • a strong recommendation against the use of warfarin (low confidence in effect estimates); imatinib (moderate confidence in effect estimates); combination prednisone, azathioprine, and N-acetylcysteine (low confidence in effect estimates); and the selective endothelin receptor antagonist ambrisentan (low confidence in effect estimates),
  • a conditional recommendation for the use of nintedanib (moderate confidence in effect estimates) and pirfenidone (moderate confidence in effect estimates), and
  • a conditional recommendation against the use of the phosphodiesterase-5 inhibitor sildenafil (moderate confidence in effect estimates) or the dual endothelin receptor antagonists macitentan and bosentan (low confidence in effect estimates).

Unchanged from the 2011 guideline was a conditional recommendation against N-acetylcysteine monotherapy, based on low confidence in effect estimate, and a conditional recommendation for antiacid therapy, based on very low confidence in effect estimate. The guideline authors noted that recommendations on treatment of pulmonary hypertension associated with IPF were deferred until the next update, and that analysis of treatment of acute exacerbation of IPF with corticosteroids, oxygen supplementation, mechanical ventilation, pulmonary rehabilitation, and lung transplantation was not a priority in this guideline.

This guideline stated that it does not provide recommendations for 1 treatment regimen over another. With the exception of the recommendation against using prednisone with azathioprine and N-acetylcysteine, the guideline does not provide suggestions for or against combination regimens or sequential therapies.

Instead, the guideline continued, strong or conditional ratings must be weighed individually, factoring in all components used to determine the grade of the recommendation, “including the confidence in effect estimates, outcomes studies, desirable and undesirable consequences of treatment, cost of treatment, implications of treatment on health equity, and feasibility of treatment.”