In the News

Guidelines for STEMI, ADA recommendations for blood pressure in diabetics, and more.

Guideline issued on management of ST-elevation myocardial infarction

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) Task Force on Practice Guidelines recently released its 2013 guideline on managing ST- elevation myocardial infarction (STEMI).

The 2013 guideline reflects research published through August 2012 and focuses on STEMI management. It offers recommendations in the following major categories:

  • onset of myocardial infarction,
  • reperfusion at a hospital capable of performing percutaneous coronary intervention (PCI),
  • reperfusion at a hospital not capable of performing PCI,
  • delayed invasive management,
  • coronary artery bypass graft (CABG) surgery,
  • routine medical therapy (e.g., beta-blockers, renin-angiotensin-aldosterone system inhibitors, and lipid management), and
  • complications after STEMI (e.g., cardiogenic shock).

The guideline's writing committee was made up of experts from cardiovascular medicine, interventional cardiology, electrophysiology, heart failure, cardiac surgery, emergency medicine, internal medicine, cardiac rehabilitation, nursing and pharmacy. Official representatives were assigned by ACP, the American College of Emergency Physicians and the Society for Cardiovascular Angiography and Interventions. The guideline was approved by the ACCF and AHA and endorsed by the American College of Emergency Physicians and the Society for Cardiovascular Angiography and Interventions.

The guideline appeared in the Jan. 29 Circulation.

ADA recommendations increase blood pressure target to below 140 mm Hg systolic in diabetic patients

A higher maximum systolic blood pressure target for diabetics is one of the most significant changes in the American Diabetes Association's (ADA) 2013 Standards of Medical Care.

The standards, which are revised annually, are based on the most current scientific evidence and provide guidance on treating children and adults with all types of diabetes. They were published online Dec. 20, 2012, and in a special supplement to the January 2013 Diabetes Care.

Several changes were made to the recommendations for 2013, the most significant being an increase in the systolic blood pressure goal for many people with diabetes from less than 130 mm Hg to less than 140 mm Hg. The revision was based on several new meta-analyses showing little additional benefit from lower targets, according to a press release. However, lower targets may still be appropriate for some patients, for example those who are younger or have a higher risk of stroke, the recommendations noted.

Another recommendation change affects hospitalized patients who have not been previously diagnosed with diabetes. If such patients have risk factors for diabetes and exhibit hyperglycemia during hospitalization, physicians should consider obtaining a hemoglobin A1c test, the standards now say. The standards have also been updated to reflect new recommendations from the Centers for Disease Control and Prevention on hepatitis B vaccination. Diabetic patients age 19 to 59 should be vaccinated, and vaccination should be considered for those 60 and over.

Recommendations on self-monitoring of blood glucose for patients who take multiple doses of insulin per day have also changed. Previously, the recommendations called for self-monitoring three or more times a day. The 2013 standards specify that these patients should test their blood glucose prior to meals and snacks, occasionally after eating, at bedtime, before exercise, when hypoglycemia is suspected or has occurred and prior to critical tasks such as driving.

The new recommendations also contain changes regarding diabetes self-management education, screening and treatment of cardiovascular risk factors in prediabetes, and emphasizing statin therapy over specific low-density lipoprotein cholesterol goals.

At VA hospitals, shorter length of stay didn't lead to higher readmissions rate

Reducing length of stay for inpatients didn't increase 30-day readmission rates, a recent study found.

Researchers reviewed records on 4,124,907 admissions from 129 acute care VA hospitals between 1997 and 2010. They analyzed trends in length of stay (LOS), 30-day readmission rates and 90-day mortality rates for all diagnoses combined, as well as for five specific diagnoses: heart failure, chronic obstructive pulmonary disease (COPD), acute myocardial infarction, community-acquired pneumonia (CAP) and gastrointestinal hemorrhage. Results were published online Dec. 18, 2012 by Annals of Internal Medicine.

Over the 14-year time frame of the study, LOS decreased for all medical diagnoses by 27% in adjusted analysis (from 5.44 days to 3.98 days; P<0.001), and relative readmission rates decreased by 16% (from 16.5% to 13.8%; P<0.001). All-cause mortality at 90 days fell by about 3% per year. However, hospitals that released patients earlier than expected given the severity of their illness had a 6% increased risk of readmission for each day earlier than expected.

Of patients with the five specific diagnoses studied, those with acute conditions had greater drops in risk-adjusted LOS, with acute myocardial infarction LOS decreasing by 2.85 days and CAP falling by 2.22 days. For 30-day readmissions, COPD saw the largest drop (17.9% to 14.6%, for an 18.4% relative decrease), with acute myocardial infarction next at a 12.4% relative decrease (22.6% to 19.8%).

The study results didn't support the researchers' hypothesis that “the intense focus on efficiency improvement” would lower LOS at the expense of increasing readmission rates, the authors wrote. On the contrary, readmissions actually fell, as did mortality rates. It's possible the findings can be explained by baseline inefficiencies in the VA system such that hospitalizations were longer than patients needed, and so reducing their length didn't have a negative effect. The VA system also initiated extensive medication reconciliation efforts during the study period—which may have helped lower readmissions—and it hired more hospitalists, who have been shown to help reduce LOS, they noted.

“Overall hospital readmission is, at best, a crude indicator of quality,” editorialists wrote. “It is preventable hospitalizations that should be our focus…punishing hospitals alone will not necessarily lower (readmission) rates….” The VA system should be seen as “the largest U.S. accountable care organization,” and as such, examined to determine the best way to enhance efficiency and quality, which this study suggests the VA has done in recent years, the editorialists concluded.

IDSA guidelines aim to reduce death, disability and cost of prosthetic joint infections

Multispecialty physician teams need to work together to reduce disability, death and costs associated with the ever-growing number of prosthetic joint infections, according to the first guidelines on the topic by the Infectious Diseases Society of America (IDSA).

Joint infections require multidisciplinary teams, including an orthopedist and an infectious disease specialist, as well as other specialists, such as internists or plastic surgeons, on a case-by-case basis, the guidelines say. In rural areas with few specialists, doctors should consider consulting with infectious disease specialists or orthopedists at referral centers. The guidelines appeared in the Jan. 1 Clinical Infectious Diseases.

Physicians should suspect a prosthetic joint infection in a patient who has any of the following:

  • sinus tract or persistent wound drainage in the skin over the joint replacement,
  • sudden onset of a painful prosthesis, or
  • ongoing pain at any time after the prosthesis has been implanted, especially in the absence of a pain-free interval, in the first few years after implantation or if there is a history of prior wound healing problems or infections.

The following guidelines apply in patients with prosthetic joint infections:

  • Those with a well-fixed prosthesis without a sinus tract who had surgery less than 30 days previously or who have had infectious symptoms for less than three weeks should be considered for debridement with retention of prosthesis.
  • Those who have more extensive infection that has affected the bone and tissue may need to have the prosthesis replaced, either in the same surgery in which the prosthesis is removed or in a later surgery.
  • Patients who cannot walk and who have limited bone stock, poor soft tissue coverage, and infections due to highly resistant organisms, may need to have the implants permanently removed. In some cases the joint may need to be fused.
  • Amputation of the limb may be necessary, but only as a last resort. Prior to amputation, the patient should be referred to a center with specialist experience in prosthetic joint infections except in emergent cases.

Four to six weeks of pathogen-specific intravenous or highly bioavailable oral antibiotic therapy following resection arthroplasty is recommended to treat prosthetic joint infections, according to the guidelines.

AHRQ issues report on prevention of health care-associated infections

The Agency for Healthcare Research and Quality (AHRQ) recently issued a report on prevention of health care-associated infections.

The report, which was published online on Nov. 30, 2012, updated the agency's 2007 report on this topic and expanded the settings to include ambulatory surgery centers, freestanding dialysis centers and long-term care facilities in addition to hospitals. Researchers included studies from the 2007 report as well as new studies published from January 2006 to April 2011, with another search update performed in January 2012. Articles were included if they described a strategy to improve adherence to at least one preventive intervention to reduce central line-associated bloodstream infections, ventilator-associated pneumonia, surgical-site infections and/or catheter-associated urinary tract infections. Strategies were defined as clinician education, patient education, audit and feedback, clinician reminder systems, organizational change, financial or regulatory incentives for patients or clinicians, or a combination. A statistical analysis that compared infection or adherence rates at baseline and post-intervention was also required for study inclusion.

Seventy-one analyses met the inclusion criteria. The researchers designated organizational change, provider education or the combination of both as “base strategies” to prevent health care-associated infection, then organized the data according to strategies used in conjunction with the base strategies: audit and feedback plus provider reminder systems, audit and feedback only, and provider reminder systems only. They examined the evidence supporting quality improvement strategies to improve adherence and infection rates, cost of the strategies, factors associated with strategies' effectiveness, and the effect of health care context.

The following key findings from the analysis assess evidence across all four of the infections of interest, including only the 30 studies (40%) that reported both adherence and infection rates:

  • Moderate-strength evidence indicates that adherence and infection rates improve when audit and feedback plus provider reminder systems and audit and feedback alone are used with the base strategies.
  • Low-strength evidence indicates that adherence and infection rates improve when provider reminder systems alone are used with the base strategies.
  • There is insufficient evidence to show that the base strategies alone improve adherence and infection rates.

The researchers commented that quantitative analysis was not possible because of the study design and that evidence synthesis was challenging, among other limitations. They also noted the need for more studies of better methodologic quality; additional research on health care-associated infections in settings other than the hospital; and more studies that provide data on implementation costs, cost savings and return on investment.

“The magnitude of the potential harm caused by [healthcare-associated infections] and their ubiquity, as well as the recent reduction in infection rates, highlight the importance and feasibility of identifying the most effective ways for health care institutions to address their prevention,” the researchers wrote. “Relatively modest improvements in research approaches have the potential to substantially strengthen the evidence and provide further insight into how to protect patients from healthcare-associated infections.”

Earlier appointments post-discharge may improve cardiac rehab attendance

Appointments for cardiac rehabilitation orientation scheduled within 10 days of hospital discharge appear to result in improved attendance compared with later appointments, a recent study indicated.

Researchers at Henry Ford Hospital in Detroit performed a randomized, single-blind controlled trial to determine whether an early appointment, defined as within 10 days of discharge, improved attendance rates at cardiac rehab orientation compared with a standard appointment, defined as within 35 days of discharge. Patients were eligible for the study if their diagnosis qualified them for cardiac rehab, if they were older than 18, if they granted access to their medical records for research purposes, and if they provided written informed consent. Recruitment took place between February and November 2011, and patients were followed through May 2012.

The study's primary outcome was attendance at the cardiac rehab orientation class, while secondary outcomes included time from discharge to class attendance, the time difference between the scheduled and actual date of the class, attendance at one or more exercise and education session, total number of exercise sessions attended, completion of cardiac rehab, and change in average exercise work load (for patients who attended at least two exercise sessions). The study results were published online Dec. 18, 2012 by Circulation.

A total of 148 patients were randomly assigned at hospital discharge to receive an early orientation appointment (n=74) or a standard appointment (n=74) and were included in the final analysis. More than half of the patients were men (56%), and slightly less than half (49%) were black. The average age was 60 ± 12 years. Median time to attendance at orientation was 8.5 days in the early group versus 42 days in the standard group (P<0.001). Attendance rates were better in the early group than in the standard group (77% vs. 59%), with a significant absolute improvement of 18% and a significant relative improvement of 56% (RR, 1.56; P=0.022). None of the secondary outcome measures differed between groups, but the authors noted that the study had low statistical power for these end points. Adverse events related to cardiac rehab also did not differ between groups.

The authors acknowledged that the study recruiters and the cardiac rehab staff could not be blinded to the patients' study groups, which may have affected the outcome, and that their results may not be generalizable to all settings because the study was conducted at a single urban hospital, among other limitations. The authors hypothesized that early appointments probably improved cardiac rehab participation for three reasons. First, patients hospitalized for a major cardiac event are often ready to make lifestyle changes, and it helps to capitalize on that mindset soon after discharge. Second, an early appointment emphasizes the importance of cardiac rehab to recovery, and third, it is easier to remember and plan for than an appointment scheduled later.

The authors recommended that national guidelines emphasize the importance of an early cardiac rehab appointment in medically stable patients. In addition, they said, each individual program should evaluate its typical interval between discharge and rehab enrollment to identify and remove any obstacles that may be causing delay. “In short, an early appointment to [cardiac rehab], barring any individual patient safety concerns, should become the national standard of care,” they wrote.

Hospitals with more hospitalists have higher patient satisfaction

Hospitals with a higher percentage of hospitalists performed modestly better on most measures of patient satisfaction, a new study found.

In a retrospective cohort study, researchers used 2009 Medicare files to identify 2,843 acute-care hospitals with 132,814 patients. They categorized hospitals into three groups based on the median proportion of patients cared for by hospitalists. For “non-hospitalist hospitals,” the median was 0%; for “mixed hospitals,” the median was 39.5%; and for “hospitalist hospitals,” the median was 76.5%. Researchers measured patient satisfaction using the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Results were published online Jan. 3 by the Journal of Hospital Medicine.

Patients at hospitalist hospitals were more likely than those at non-hospitalist hospitals to recommend the hospital (69.4% vs. 65.1%; P<0.001) and to report higher overall satisfaction (65.9% vs. 63.6%; P<0.001). Hospitalist hospitals did better in six specific domains of patient satisfaction; the biggest difference was in discharge planning (80.3% of patients at hospitalist hospitals vs. 79.1% at mixed hospitals vs. 78.1% at non-hospitalist hospitals; P<0.001). Other domains where hospitalist hospitals received better scores than non-hospitalist hospitals were nursing services, quiet rooms, communication with nurses, pain control and medication management.

Hospitalist care wasn't associated with satisfaction regarding communication with physicians or cleanliness of rooms. Results were similar when researchers used multi-variable models that accounted for differences in such hospital characteristics as number of beds, teaching status and location.

The results, said the researchers, were “surprising and reassuring” and may comfort clinical leaders and policymakers who have advocated greater use of hospitalists. Communication between hospitalists and patients is a potential area of improvement, they noted, since it may be that patients don't know their hospitalists as well as the primary care doctors who orchestrate care in non-hospitalist facilities. The findings suggest that “adoption of the hospitalist model…should not detract from achieving the goal of more patient-centered care,” they concluded.

Revised guidelines to manage pain, agitation, delirium in ICU patients

The American College of Critical Care Medicine (ACCM) has revised its clinical practice guidelines for managing pain, agitation and delirium in critically ill adults.

The guidelines update those released in 2002 and appeared in the JanuaryCritical Care Medicine. Evidence for the guidelines was ranked as high (A), moderate (B) or low (C), and recommendations were rated as strong (1) or weak (2). Statements and recommendations include the following:

  • Pain should be routinely monitored in all ICU patients (1B). The Behavioral Pain Scale and the Critical-Care Pain Observation Tool are the most valid and reliable for monitoring pain in medical, postoperative and trauma patients who are unable to self-report and in whom motor function is intact (B). Vital signs, or observational pain scales that include vital signs, should not be used alone for pain assessment in ICU patients (2C).
  • Intravenous (IV) opioids should be the first-line drug class of choice to treat non-neuropathic pain in critically ill patients (1C). For treatment of neuropathic pain, either enterally administered gabapentin or carbamazepine, in addition to IV opioids, is recommended (1A).
  • Maintaining light levels of sedation in ICU patients is associated with improved outcomes (B). The Richmond Agitation-Sedation Scale and Sedation-Agitation Scale are the most valid and reliable sedation assessment tools for measuring quality and depth of sedation (B). In mechanically ventilated patients, sedation strategies using non-benzodiazepine (propofol or dexmedetomidine) sedatives may be preferred over benzodiazepines (2B).
  • The most valid and reliable delirium monitoring tools in the ICU are the Confusion Assessment Method for the ICU and the Intensive Care Delirium Screening Checklist (A).
  • Baseline risk factors that are positively and significantly associated with developing delirium in the ICU are preexisting dementia, history of hypertension and/or alcoholism, and high severity of illness at admission (B).
  • To reduce incidence and duration of delirium, early mobilization of ICU patients is recommended whenever feasible (1B). Use of haloperidol or atypical antipsychotics is not suggested to prevent delirium (2C).
  • Atypical antipsychotics may reduce the duration of delirium in adult ICU patients (C), but there is no published evidence that haloperidol reduces the duration of delirium in these patients.
  • For mechanically ventilated patients, analgesia-first sedation is suggested (2B), as well as either daily sedation interruption or a light target level of sedation (1B).

The guidelines were supported by the Society of Critical Care Medicine and the American Society of Health-System Pharmacists. They were also reviewed and endorsed by the American College of Chest Physicians and the American Association of Respiratory Care, supported by the American Association for Respiratory Care, and reviewed by the New Zealand Intensive Care Society.

Many hypertensive black patients don't receive diuretics

More than half of black patients with uncontrolled hypertension don't receive diuretics, despite recommendations favoring their use as a first-line agent, a study found.

The study was conducted in the post-acute care division of a large, urban Medicare/Medicaid-certified home health organization. Results appeared online Dec. 28, 2012 in the American Journal of Hypertension.

Of the 658 patients, 300 (46%) took a diuretic, including 30 who were taking more than one. Among these 300 patients, 68% received a thiazide diuretic, 33.3% received a loop diuretic, and 4.3% received a potassium-sparing diuretic (including 3% who took an aldosterone receptor blocker). Participants who were not taking a diuretic took fewer antihypertensive medications (1.7 vs. 2.9 medications; P<0.0001) compared with those who were. They had a higher mean diastolic blood pressure (89.2 vs. 85.5 mm Hg; P=0.0005) and were more likely to have a systolic blood pressure of 160 mm Hg or greater (57.6% vs. 49.0%; P=0.04).

Among the 94.5% of participants taking antihypertensive medication, 26.5% (n=165) took just one drug. In this group, only 12% (n=19) took a diuretic. The percentage taking a diuretic increased to 43% among those taking two drugs, 73% among those taking three drugs and 90% among those taking four or more medications. Diuretics were associated with lower systolic and diastolic blood pressure. The mean systolic difference was −5 mm Hg (95% CI, −8.80 to −1.21; P=0.01) and the mean diastolic difference was −3.79 mm Hg (95% CI, −6.16 to −1.41; P=0.002).

The authors also noted that sometimes the diuretic dose wasn't high enough. While 67.3% of patients who were taking a diuretic received hydrochlorothiazide, in 93.1% of cases the dose was 25 mg/d or less. The rest received a higher dose or a combination with a potassium-sparing agent.