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From the February ACP Hospitalist, copyright © 2017 by the American College of Physicians

C. difficile transmission low after contact precautions discontinued

One Swiss hospital discontinued contact precautions for most patients with Clostridium difficile and found very little transmission of the disease between patients, according to a recent study.

The study was conducted from January 2004 to December 2013 in a tertiary care hospital in Switzerland. At the start of the study, the hospital discontinued contact precautions for patients with C. difficile, except for those with hypervirulent ribotypes (027 or 078) or stool incontinence. Hospital personnel still wore disposable gloves for all body substance contact, and infected patients used dedicated toilets. The patients stayed in rooms with two to four beds. The study was published by Clinical Infectious Diseases on Nov. 15, 2016.

To determine whether C. difficile spread from the index cases (n=279), all contacts of those patients (n=451) were screened for toxigenic C. difficile by culturing rectal swabs. Toxigenic C. difficile was detected in 27 contacts (6%) after a median contact time of five days. However, polymerase chain reaction testing found identical ribotypes in only six index-contact pairs (1.3% of the total study population). Next-generation sequencing was performed on four of the pairs and confirmed transmission in two contact patients, leading researchers to suspect that transmission was unlikely in the other two sequenced pairs.

The results show that the rate of transmission was low and no outbreaks were recorded in 10 years after discontinuing contact precautions, the authors concluded. “Our study challenges the routine use of contact precautions for patients with [C. difficile infection] in acute care hospitals with an effective infection control program, mostly 1- to 2-bed rooms, short contact time (5 days) and a low [C. difficile] incidence—potentially saving resources and improving patient care,” they wrote.

The findings may not be generalizable to hospitals with high C. difficile incidence, a predominance of the hypervirulent ribotypes, less effective infection control, and longer stays, the authors noted. The study was also limited by the number of patients lost to follow-up and the possibility of infections being missed by the screening method. However, the study is concordant with the evidence base, which offers moderate to poor evidence for contact precautions beyond those employed in the study and alternative explanations for observed increases in C. difficile, such as exposure to antibiotics, the authors said.

AHA/ASA scientific statement on telestroke quality measures

Telestroke systems are the focus of a recent scientific statement from the American Heart Association/American Stroke Association.

The statement reviews the history of telestroke and current systems and evidence for telestroke programs. It also suggests measures for ongoing quality and outcome monitoring to improve performance and to enhance the delivery of care. The suggestions about possible measures cover processes, outcomes, tissue-type plasminogen activator use, patient and provider satisfaction, and telestroke technology. Additional topics addressed by the statement include licensing, credentialing, training, and documentation. The statement was published by Stroke on Nov. 3, 2016.

The authors note that they do not intend to add unnecessary burden to telestroke networks, but that they believe monitoring of quality is important in this relatively new field. “Although evidence supporting the equivalence of telestroke to in-person care is accumulating, the limits of medical care provided remotely by telemedicine remain to be defined,” the statement says. “It is hoped that these suggestions serve as a foundation for ongoing improvement of telestroke networks and increasing quality across all providers.”

Study identifies additional factors that predict 30-day readmissions

Disability and certain social determinants of health affect the risk of 30-day readmission beyond factors currently included in Medicare's risk adjustment, a recent study found.

The retrospective cohort study used the Health and Retirement Study-Medicare claims data and Healthcare Cost and Utilization Project State Inpatient Databases for Florida and Washington linked with the Census American Community Survey. The study's outcomes were 30-day readmissions after hospitalization for pneumonia, heart failure, or acute myocardial infarction. Results were published by the Journal of General Internal Medicine on Nov. 15, 2016.

For pneumonia patients, having more difficulty with activities of daily living (ADL) was associated with higher readmission risk in both datasets. The researchers noted that they had expected ADL limitations to be a predictor for all three conditions; however, it was not identified as an issue in heart failure or myocardial infarction. For heart failure, having children or wealth was associated with lower risk of readmission in one dataset. For acute myocardial infarction, nursing home status was associated with increased readmission risk in one dataset. Nonwhite race was a predictor of readmission for all three conditions in one dataset, but not in the other, the researchers noted. No predictors were significant across all the data.

Extrapolating from the data, the researchers described two hypothetical heart failure patients with similar profiles, except that one is white and married, with no ADL limitations and wealth, while the other is African-American, lives alone, and has significant ADL limitations and no wealth. The patients would be scored the same in the CMS risk-adjustment model, yet the latter patient would have a 23-point higher risk of readmission according to this study's findings.

The authors called for consideration of these findings in future revision of risk-adjustment measures. “Our results suggest that a first priority may be to focus on the inclusion of disability measures such as ADL limitations and nursing home needs (already extensively documented in electronic health records) as additions to comorbidities for risk adjustment,” they wrote.

Early warning systems helped in hospitals' sepsis care

Strategies to detect critical illness, particularly sepsis, in non-ICU patients were analyzed in a supplement to the November 2016 Journal of Hospital Medicine.

After an introductory article established a conceptual framework for early detection, prevention, and mitigation of critical illness in non-ICU patients, the researchers described such an effort in the 21 hospitals of the Kaiser Permanente Northern California system. The data-driven approach resulted in changes in the standardized diagnostic criteria used to label patients, a dramatic increase in the use of lactate testing in the ED, and increases in the number of sepsis patients receiving early antibiotics and central venous catheters.

Another article described the deployment of an early detection system in a two-hospital pilot within the same system. The pilot demonstrated that sepsis severity scores and probability estimates could be provided to hospitalists in real time, and it identified issues to address before deployment of the early warning system to other hospitals. The warning system used a Java application to make scores and probability estimates visible in the EHR every six hours.

Yet another article described the implementation process for these systems. It found that the warning system could successfully be incorporated into hospitalists' workflows, but the article also identified problem areas, including documentation following an alert. “Other areas that must be addressed prior to disseminating the intervention include the need for educating clinicians on the rationale for deploying the [early warning score], careful consideration of interdepartment service agreements, clear definition of clinician responsibilities, pragmatic documentation standards, and how to communicate with patients,” the article said. Another article described how the hospitals integrated supportive care into the warning system.

The last article described a sepsis recognition program that began with 60 academic and community hospitals in four U.S. regions. The Surviving Sepsis Campaign Phase IV Sepsis on the Wards Collaborative focused on early recognition through protocol-driven regular nurse screening and was funded by the Gordon and Betty Moore Foundation. The supplement was also funded by the Foundation, as well as the Permanente Medical Group Inc. and Kaiser Foundation Hospitals Inc.

In the News is a product of ACP Hospitalist Weekly, an e-newsletter provided every Wednesday by ACP Hospitalist. To receive ACP Hospitalist Weekly, call Customer Service at 800-543-1546, ext. 2600, or direct at 215-351-2600; send an email; or subscribe online.

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Guideline corner: WHO on prevention of surgical site infections

The World Health Organization (WHO) has released the first international set of guidelines for the prevention of surgical site infections (SSIs).

A panel of 20 experts reviewed 26 studies to create the evidence-based guidelines, which were published on Nov. 2, 2016, in two online papers by The Lancet Infectious Diseases. The guidelines recommend 29 precautions that clinicians should take before, during, and after surgery to reduce the risk of SSIs. Below are several takeaways for hospitalists.

The preoperative measures include:

  • All patients should bathe or shower before surgery, but hair should either not be removed or, if absolutely necessary, should be removed with a clipper. Perioperative shaving is strongly discouraged;
  • Immunosuppressive medications should not be discontinued before surgery;
  • Patients with known nasal carriage of Staphylococcus aureus who are undergoing cardiothoracic or orthopedic surgery should receive perioperative intranasal applications of mupirocin 2% ointment, with or without a combination of chlorhexidine gluconate body wash;
  • When indicated, clinicians should administer surgical antibiotic prophylaxis within 120 minutes of the incision while considering the antibiotic's half-life; and
  • In adults undergoing elective colorectal surgery, mechanical bowel preparation should not be used without the administration of oral antibiotics.

The intraoperative and postoperative measures include:

  • Protocols for intensive perioperative blood glucose control should be used in patients with and without diabetes who are undergoing surgical procedures;
  • Perioperative surgical antibiotic prophylaxis should not be continued because of the presence of a wound drain for the purpose of preventing SSIs. Surgical antibiotic prophylaxis should not be prolonged after the procedure;
  • Adults undergoing general anesthesia with endotracheal intubation for surgery should receive 80% fraction of inspired oxygen intraoperatively and, if feasible, for two to six hours in the immediate postoperative period;
  • In high-risk, primarily closed surgical incisions, prophylactic negative-pressure wound therapy is suggested;
  • No type of advanced dressing should be used over a standard dressing on primarily closed surgical wounds;
  • Triclosan-coated sutures should be used in all types of surgery;
  • Goal-directed fluid therapy is suggested for use intraoperatively; and
  • Warming devices should be used in the operating room and during the procedure to maintain patients' normal body temperatures.

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