In the News

Central line infection rates, organizational characteristics of hospitalist groups, and more.

Central line infections in ICUs fell 58% between 2001 and 2009

Central line-associated bloodstream infections (CLABSIs) in ICUs dropped 58% between 2001 and 2009, the Centers for Disease Control and Prevention reported in March.

CDC researchers multiplied central line utilization and CLABSI rates by estimates of the total number of patient-days in ICUs, inpatient wards and outpatient hemodialysis facilities. They used the Healthcare Cost and Utilization Project's National Inpatient Sample and the Hospital Cost Report Information System to identify total inpatient days; CLABSI and central line use rates came from the National Nosocomial Infections Surveillance Systems for 2001 estimates (ICUs only) and from the National Healthcare Safety Network (NHSN) for 2009 estimates (ICUs and inpatient wards). Total number of outpatient hemodialysis patient-days in 2008 came from the U.S. Renal Data System; outpatient hemodialysis central line utilization data came from the Fistula First Breakthrough Initiative; and hemodialysis CLABSI rates were estimated from the NHSN. Results were published online March 1 by the CDC's Morbidity and Mortality Weekly Report.

ICU CLABSIs fell to about 18,000 cases in 2009 from about 43,000 cases in 2001. Reductions in infections caused by Staphylococcus aureus were greatest (73% reduction; rate ratio [RR], 0.27; 95% CI, 0.238 to 0.294), followed by those caused by Enterococcus species (55% reduction; RR, 0.45; 95% CI, 0.408 to 0.491), Candida species (46% reduction; RR, 0.54; 95% CI, 0.487 to 0.606) and gram-negative pathogens (37% reduction; RR, 0.63; 95% CI, 0.568 to 0.692). Overall, the decline in infections saved up to 6,000 lives and $414 million in potential excess health care costs in ICUs in 2009 alone, and saved an estimated 27,000 lives and $1.8 billion in excess health care costs in ICUs since 2001. Still, a substantial number of CLABSIs occurred in inpatient wards and outpatient hemodialysis centers. While data for 2001 weren't available, there were an estimated 23,000 CLABSIs in inpatient wards in 2009 and 37,000 in outpatient hemodialysis centers in 2008.

Collaboration among health care facilities, professional societies and state and federal agencies to implement proven best practices for central line insertion has likely helped reduce CLABSIs in ICUs, the report concluded. Such efforts may have limited impact outside the ICU, where central lines are less frequently inserted, so extra prevention strategies should be developed, it said.

Organizational characteristics of hospitalist groups vary widely

Hospitalists groups differ widely on characteristics like patient volume, continuity of care and the role of midlevels, a study found.

Researchers interviewed the leaders of five hospitalist groups in the Baltimore-Washington area. Prior to the interview, researchers reviewed existing literature to determine the specific organizational characteristics that might affect patient outcomes and spoke with hospitalist leaders at other institutions. The five hospitals were all community teaching facilities that participate in the CareScience Care Data Exchange program, a technology that enables information exchange between health care organizations. Researchers used the CareScience database to retrospectively obtain demographics, health care outcomes and clinical results from adult patients treated by hospitalists at the five hospitals between July 2008 and June 2009. Most results were descriptive due to the small sample size. The study was published in the March Journal of Clinical Outcomes Management.

The hospitalist programs surveyed had existed from four to 13 years, and ranged in annual hospitalist admissions from 2,092 to 6,022. Bed sizes at the hospitals ranged from 300 to 700. When physicians and midlevels were factored in, they ranged from 299 to 502 admissions per clinician annually. The daily patient cap (i.e., maximum number of patients managed) per hospitalist ranged from eight to 16. Two groups had a shift model whereby hospitalists rotated through day, night and admitting shifts and each person had a distinct role. The other three had hospitalists perform a combination of duties daily (including admissions, cross-coverage and follow-up). All did daily rounds; none rounded with nurses, and only one rounded daily with a dedicated hospitalist case manager. The maximum number of allowable consecutive days worked ranged from five to ten. In all cases, salary bonuses were tied to productivity. Annual turnover varied from 17% to 44%.

Although cardiac arrest and venous thromboembolism rates didn't differ significantly by hospital, the inpatient mortality rates and 14-day and 30-day readmission rates were significantly different. It appeared that the older hospitalist programs achieved better outcomes with lower mortality and reduced lengths of stay, the authors noted. In particular, the youngest program had the highest in-hospital death rate and the longest hospital and ICU lengths of stay, although it had the lowest rates of readmission. That group also saw fewer patients per clinician and used moonlighters for overnight coverage, they noted. “Dedicated overnight hospitalists may improve quality through continuity of care and in comparison to non-hospitalists,” the authors wrote, adding that further study is needed to see how organizational characteristics affect clinical outcomes. The study's limitations include reliance on self-report by one hospitalist leader for organizational information, lack of patient-level data, and the descriptive nature of the results, they noted. Also, the nature of the outcomes did not allow for consideration of possible confounders, they wrote.

AHA releases scientific statement on managing PE, DVT

The American Heart Association recently issued a scientific statement on the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT), and chronic thromboembolic pulmonary hypertension (CTEPH).

The ACC proposed definitions for massive and submassive PE. Massive PE is an acute PE with sustained hypotension (systolic blood pressure of 90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular dysfunction), pulselessness, or persistent profound bradycardia (heart rate 40 beats per minute with signs or symptoms of shock). Submassive PE is an acute PE without systemic hypotension (systolic blood pressure 90 mm Hg) but with either right ventricular dysfunction or myocardial necrosis. The statement was published in the April 26 Circulation.

Recommendations include:

  • Patients with objectively confirmed acute PE and no contraindication to therapeutic anticoagulation should be given subcutaneous low-molecular-weight heparin, intravenous or subcutaneous unfractionated heparin (UFH) with monitoring, unmonitored weight-based subcutaneous UFH, or subcutaneous fondaparinux. These should be given during the diagnostic workup for those with intermediate or high clinical probability of PE and no contraindications.
  • Fibrinolysis is reasonable for patients with massive acute PE and acceptable risk of bleeding complications, and also may be considered for those with submassive acute PE with clinical evidence of adverse prognosis (new hemodynamic instability, worsening respiratory failure, severe right ventricular dysfunction, or major myocardial necrosis) and low bleeding risk. It is not recommended for patients with low-risk PE or undifferentiated cardiac arrest.
  • For patients with massive PE and contraindications to fibrinolysis, or who remain unstable after fibrinolysis, either catheter embolectomy and fragmentation or surgical embolectomy is reasonable, depending on local expertise. These treatments also may be considered for those with submassive acute PE with clinical evidence of adverse prognosis.
  • Adults with confirmed acute PE or proximal DVT with contraindications to anticoagulation or with active bleeding complication should receive an inferior vena cava (IVC) filter. Once contraindications or complications have resolved, anticoagulation should be resumed.
  • IVC filters are reasonable for patients with recurrent acute PE despite therapeutic anticoagulation, and may be considered for those with acute PE and very poor cardiopulmonary reserve, including those with massive PE. A filter should not be used routinely as an adjuvant to anticoagulation and systemic fibrinolysis for acute PE.
  • Adult patients with IFDVT who take oral warfarin as first-time, long-term anticoagulation should have warfarin overlapped with initial anticoagulation for a minimum of five days and until the international normalized ratio (INR) is 2.0 or higher for at least 24 hours, then targeted to an INR of 2.0 to 3.0.
  • Patients with objectively proven CTEPH should be promptly evaluated for pulmonary endarterectomy, even if symptoms are mild.

U.S. and U.K. doctors differ on reporting conflicts, errors

Physicians in both the U.S. and the United Kingdom report differences between their professional values and their actual behavior, according to recent survey results.

Researchers collected responses from about 1,900 American physicians in various specialties from 2003 to 2004 and about 1,100 physicians in the U.K. in 2009 to a series of questions about their professional values. The results, published online March 7 in BMJ Quality and Safety, revealed differences in beliefs and practices between the two countries, as well as gaps between physicians' values and actions.

For example, nearly a fifth of doctors in both countries reported direct personal experience with an impaired or incompetent colleague in the past three years, but one-third of those respondents had not reported the colleague to authorities. U.K. physicians were far more likely (34% vs. 12%) to list fear of retribution as a reason for their failure to report—an issue that has been previously noted in British medicine, the study authors said. The U.S. physicians were more likely to respond to incompetence by not referring patients to the colleague, an option which is often less available to U.K. physicians.

The doctors also differed on their acceptance of conflicts of interest: 83% of U.S. doctors reported receiving samples or gifts from industry (compared to 73% of British doctors), 47% thought business ventures with patients were never appropriate (60% in the U.K.), and 9% had actually provided care for a person with whom they had a direct financial relationship (1% in the U.K.).

U.S. physicians were more strongly in favor of disclosing their own financial relationships with industry and benefits and risks of treatment to patients than their British peers (65% vs. 59% and 88% vs. 74%, respectively). However, they were less likely to believe in disclosing all significant medical errors to affected patients (64% vs. 70%) due to the fear of being sued (21% vs. 13%).

The results indicate that physicians in both countries share a core of professional values, but that they have some differences that may be a result of the contexts in which they practice, study authors said. Given that both countries are currently working on major health care reform, physicians should advocate for creation of health care systems that encourage behavior congruent with physicians' values, they concluded.