In the News

New CPR guidelines, score to predict outcomes in CAP patients with kidney injury, sleep apnea questionnaire, and more.

New CPR guidelines: compressions first, then rescue breathing

Updated cardiopulmonary resuscitation (CPR) guidelines say to start with chest compressions, followed by checking the airway and giving rescue breaths.

The guidelines by the American Heart Association, published in the Nov. 2 2010 Circulation, update those issued in 2005. The previous guidance to check the airway and give breaths before compression results in a potential delay of compressions while a responder retrieves a barrier device or positions a victim's head to open the airway, the new guidelines said. Other changes of particular interest to health care providers include:

  • “Look, Listen and Feel” has been removed from the Basic Life Support (BSL) algorithm, as those steps are time-consuming and inconsistent. Instead, providers should immediately activate the emergency response system and start chest compressions for unresponsive adults who are not breathing or not breathing normally (i.e., gasping). Chest compressions should be started before giving rescue breathing.
  • The recommended depth of chest compression for adult victims is now at least 2 inches (previously 1 1/2 to 2 inches). The rate, 100 compressions per minute, should allow for complete recoil of the chest after each compression while minimizing pauses and avoiding excessive ventilation.
  • Many tasks performed by health care providers during resuscitation attempts can be done concurrently by a team of trained rescuers. Those tasks include compressions, airway management, rescue breathing, rhythm detection, shock delivery and drug delivery, if appropriate. Provider training “should focus on building the teams as each member arrives or quickly delegating roles if multiple rescuers are present,” they said.
  • Untrained bystanders should be encouraged to use compression-only CPR.

Points of “continued emphasis” include that providers should take no more than 10 seconds to see if a pulse is present; be trained to spot unusual presentations of sudden cardiac arrest; and keep chest compression interruptions to a minimum.

RIFLE score predicts outcomes for CAP patients with kidney injury

The RIFLE score can be an effective tool for assessing acute kidney injury in patients with community-acquired pneumonia (CAP), a study found.

The prospective observational study included 1,241 patients admitted to the hospital with CAP. Researchers used the RIFLE (Risk, Injury, Failure, Loss, End-stage kidney disease) to classify the patients. Based on their creatinine levels at admission, 82% of the patients had no acute kidney injury. Of the other 18%, 130 patients were classified in the risk group (creatinine of at least 1.5 times baseline), 63 were in the injury group (creatinine at least twice baseline) and 30 were in the failure group (creatinine at least triple baseline). The study was published in the October 2010 CHEST.

On multivariate analysis, the patients' RIFLE class independently predicted their risk of 30-day mortality and need for mechanical ventilation, inotropic support and renal replacement therapy. The risk for these outcomes increased in a stepwise fashion with increasing RIFLE class. The researchers also identified several factors that predicted patients' risk of developing acute kidney injury: severity of pneumonia (adjusted odds ratio [AOR], 1.74; P<0.0001); elevated C-reactive protein (AOR, 1.04; P<0.0001); and prior use of angiotensin-converting enzyme inhibitors or angiotensin-II-receptor blockers (AOR, 1.77; P=0.005).

This study may be the first to describe the increase in morbidity and mortality associated with acute kidney injury in patients admitted for CAP, the authors said. Particularly striking was the finding that even modest increases in creatinine (as in those patients in the “risk” class) were associated with significantly higher risk for mechanical ventilation, inotropic support and 30-day mortality compared to patients without acute kidney injury. This finding should lead physicians to focus on prompt detection and early aggressive management of these CAP patients, the authors said. The RIFLE score is an easy way to assess patients' kidney injury and predict outcomes, they said.

Sleep apnea questionnaire predicts postoperative complications

A questionnaire designed to identify patients with obstructive sleep apnea also predicted surgical patients' risk of postoperative complications, according to a study.

The historical cohort study included 135 patients undergoing elective surgery at one hospital. Before surgery, all patients were given the eight-question STOP-BANG (Snoring, Tiredness during daytime, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, Gender) questionnaire. Responses to the questionnaire indicated that 41.5% of the patients were at high risk of obstructive sleep apnea syndrome. Patients in this high-risk group had a higher rate of postoperative complications than those who were at low risk of sleep apnea (19.6% vs. 1.3%, P<0.001). These patients also had a longer length of stay compared to those at low risk (3.6 days vs. 2.1 days, P=0.003).

After multivariate analysis, high risk of obstructive sleep apnea and American Society of Anesthesiologists Physical Status Class of 3 or higher were associated with a significantly higher risk of postoperative complications. The researchers also assessed the accuracy of the questionnaire by calculating the area under the receiver operating characteristic curve, which was 0.82. A STOP-BANG score of 3 or higher had a sensitivity of 91.7%; a specificity of 63.4%; a positive predictive value of 19.6%; and a particularly high negative predictive value, the study authors noted, of 98.7%. The results were published in the October 2010 Archives of OtolaryngologyHead and Neck Surgery.

This is the first study to find that the concise, easy-to-administer questionnaire can indicate heightened (approximately ten-fold) risk of postoperative complications in elective surgery patients, the study authors concluded. Other research has proposed a number of causes for the association between sleep apnea and postoperative complications, but data on the ideal perioperative management of patients with the condition is limited. The perioperative use of continuous positive airway pressure may be beneficial, the study authors said. They called for future research to provide external validation of this study's results.

Hospitalizations for diabetes increase, especially among women in their 20s, 30s

The number of hospitalizations with a primary or secondary diagnosis of diabetes increased dramatically between 1993 and 2006, especially among younger people, a study found.

Researchers gathered their statistics from hospital discharges included in the Nationwide Inpatient Sample and the results were published online Oct. 12, 2010 by the Journal of Women's Health. Over the 14-year period, diabetes hospitalizations increased 65.3% overall. The largest increase in hospitalizations, of 102%, was among patients 30 to 39 years old. Younger women saw greater increases than younger men, with diabetes hospitalizations increasing 63% in 20- to 29-year-old women and 118% in 30- to 39-year-olds (compared to 46% and 85%, respectively, in men). At age 50, the trend flipped, with more men over age 50 being hospitalized for diabetes than women. During this same time period, overall hospitalization rates for adults declined, the study authors noted.

The analysis also looked at the primary diagnoses associated with these hospitalizations. Excluding pregnancy-related hospitalizations, diabetes with complications was the top diagnosis in all age groups, but psychiatric disorders also accounted for a substantial proportion of younger patients' hospitalizations. Affective disorders were the second most common diagnosis in women 20 to 39 years of age, while schizophrenia was the fifth biggest among young men. Younger age and female gender have been associated with increased risk of depression in diabetics, and atypical neuroleptics have been associated with incident diabetes, the study authors noted.

Overall, the increases found by the study may reflect increasing diabetes prevalence in the adult population, the authors said. The differences between men and women may be related to previous findings that women diabetics receive less preventive care and aggressive medical management. The authors recommended more focus on diabetes prevention and research to assess whether the growth in hospitalizations has resulted from increasing prevalence of diabetes or an increasing burden of comorbid disease.

Inpatient care experience improved in many areas, survey finds

Inpatient care improved between 2008 and 2009 in all areas except doctors' communication, a survey found.

Researchers analyzed data collected from patients at 2,774 hospitals in both March 2008 and March 2009. Patient response rates averaged 34% in both time periods. The survey was administered between 48 hours and six weeks after discharge by mail, telephone, mail with telephone follow-up, or interactive voice response on the phone. It was administered to a random sample of adult patients after an inpatient stay of at least one night for medical, surgical or maternity care.

The instrument, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, asked patients to measure communication with doctors and nurses, staff responsiveness, pain management, communication about medicine, discharge information, the cleanliness and quietness of the hospital, and whether the hospital should be recommended overall. The survey was in the November 2010 Health Affairs.

Hospitals were required to collect data from the HCAHPS survey—overseen by the Centers for Medicare and Medicaid Services—by July 2007, and to report that data in March 2009, or be penalized by losing 2% of their annual payment update, the authors noted. Participation in public reporting rose 55% to 80% between March 2008 and March 2009, they said.

Ratings on eight of nine measures improved significantly between 2008 and 2009 (P<0.01), though all improvements were less than one percentage point. Improvement was greatest for discharge information, staff responsiveness and quietness. The smallest improvement was for hospital recommendation. There was no significant change in scores for doctor communication (P=0.254). Improvements didn't differ significantly by hospital size or ownership, location, teaching status or patient mix.

The results of the survey show that within just one year of public reporting, hospitals can see meaningful improvement, and “[H]ealth care entities are able to use CAHPS feedback to improve patient experience,” the authors wrote. The finding of only slight improvement in overall hospital recommendations may reflect the fact that patients partially base impressions on the prior experiences of loved ones and on a hospital's general reputation, not just their own experience during one stay, they said.