In the News

Cardiac arrest response, readmission risk score, and more.

AHA: Improve response to inpatient cardiac arrest

The American Heart Association recommended several strategies for improving patients' survival after in-hospital cardiac arrest (IHCA) in a recent consensus statement.

The group of experts who reviewed the existing literature and wrote the statement defined IHCA as cardiac arrest that occurs in a hospital (whether the patient is admitted or not) and for which resuscitation is attempted with chest compressions, defibrillation or both. They noted that research is lacking on IHCA and that most current guidelines are extrapolated from knowledge about out-of-hospital cardiac arrest.

The consensus statement offered several specific recommendations for hospital clinicians and leaders:

  • Establish and report patient self-determination of care documentation, including explicit do-not-attempt-resuscitation status, as a routine practice in all admissions.
  • Establish competency of all hospital staff in recognizing cardiac arrest, performing chest compressions, and using an automated external defibrillator.
  • Implement best practices across all phases of IHCA care with a continuous quality improvement program.
  • Track and report complete IHCA incidence and survival to hospital discharge, as well as functional outcome at discharge, using universal definitions to ensure that the numerator and denominator are standardized for IHCA across all hospitals.
  • Implement a standardized, evidence-based prognostication approach to prevent premature withdrawal of life-sustaining therapy.
  • Optimize the process for successful organ and tissue recovery after death.

The statement also offered additional specifics on best practices for IHCA response. In addition to the limitations of current knowledge and reporting on IHCA, the common perception that it is hopeless presents an impediment to quality improvement, the statement said. Much could be done by clinicians, institutional leaders, regulatory bodies and research funding agencies to improve response to IHCA, the authors concluded.

The consensus statement appeared in the April 9 Circulation.

Score can predict readmission risk

A prediction score can identify before discharge the likelihood of a potentially avoidable 30-day readmission, a recent study suggests.

In a retrospective cohort study, researchers analyzed all patient discharges from medical services at Brigham and Women's Hospital in Boston from July 2009 through June 2010. They identified potentially avoidable 30-day readmissions using a computerized algorithm based on administrative data. Results were published online March 25 by JAMA Internal Medicine.

Readmissions were considered to be unavoidable if they were planned or if they were unforeseen due to newly developed conditions unrelated to known diseases during the index hospitalization. Avoidable readmissions were related to a previously coded medical condition or resulted from a treatment complication. The researchers looked at readmissions to Brigham and Women's as well as Massachusetts General Hospital and Faulkner Hospital; all three are affiliated with the Partners HealthCare network.

Among 10,731 eligible discharges, 2,398 (22.3%) were followed by a 30-day readmission. Of these, 879 (8.5% of all discharges) were identified as potentially avoidable. Researchers randomly divided the admissions not followed by a 30-day readmission (n=8,333) and the potentially avoidable readmissions into a derivation and validation set to determine the prediction score.

The score identified seven independent factors, referred to with the acronym HOSPITAL: Hemoglobin at discharge, discharge from an Oncology service, Sodium level at discharge, Procedure during the index admission, Index Type of admission, number of Admissions during the last 12 months and Length of stay. The HOSPITAL score had good calibration and fair discriminatory power (C statistic, 0.71).

It was surprising that none of the most frequent comorbidities in readmitted patients were retained as a factor in the final model, the researchers noted. “The hypothesis that comorbidities or causes of admission do not matter as much as illness severity or clinical instability is attractive and has intuitive appeal,” they wrote. The HOSPITAL score, which can be used for all patients regardless of their main admission cause, enables physicians to target intensive transitions-of-care interventions to those who might benefit the most from them, they concluded.

However, an invited commenter noted that more research is needed on how to help patients at risk of readmission, since currently recommended interventions are resource intensive. One intervention that doesn't seem to work is having inpatient clinicians communicate directly with outpatient clinicians at discharge, another study in the March 15 JAMA Internal Medicine found. Fifty-four percent of inpatient clinicians don't attempt to directly communicate with the outpatient physician during discharge at all, and even among those who did, no reduction in readmissions was associated with direct communication, the study found.

Hospitalists' PICC practices, knowledge need to be improved

Hospitalists prefer peripherally inserted central catheters (PICCs) to central venous catheters but don't always employ safe practices in their use, a recent survey found.

Researchers invited 227 hospitalists at 10 Michigan hospitals to participate in an anonymous Web-based survey, which was administered between August and September 2012. Survey questions were derived from the authors' previously published conceptual framework of PICC-related complications (which views complications as arising from patient-, clinician- and device-related characteristics). The questions aimed to capture hospitalist experience, reported practice, opinions and knowledge regarding PICCs, as well as hospitalist type (full- or part-time), years of practice and care-delivery model (direct care vs. learner-based care). Results were published online March 22 by the Journal of Hospital Medicine.

One hundred forty-four hospitalists, or 63%, responded to the survey. Eighty-one percent were full-time hospitalists and the average time in practice was 5.6 years. Most (81%) felt that PICCs were safer to insert than central venous catheters and that they were preferred by patients (74%). Just 4% knew that PICC-tip position should be checked to reduce the risk of venous thromboembolism (VTE), and 12% knew that the site of PICC insertion has also been associated with VTE risk. Forty-eight percent said they don't remove a PICC until a patient is ready for discharge, and 51% said that they had forgotten a patient had a PICC on at least one occasion. Forty-seven percent said that 10% to 25% of PICCs inserted at their hospitals might be inappropriate.

Study limitations include a small sample size, somewhat low response rate, and under-representation of federal facilities (n=1). The findings nonetheless suggest that PICC use needs to be watched more closely, especially since such use has increased substantially in the last 10 years, the authors wrote. Device-reminder alerts, education about potential complications, and efforts to identify and remove unnecessary PICCs may mitigate some issues highlighted in the survey results. Also, “there is a growing need for the development of appropriateness criteria to guide vascular access in inpatient settings,” the authors wrote. Until such development, “hospitals should consider instituting policies to monitor PICC use with specific attention to indications for insertion, duration of placement and complications,” they concluded.

ED visits are usually for emergencies rather than ‘primary care’

Only about 6% of emergency department (ED) visits could have been treated by a primary care visit instead, a recent study found.

To determine whether patients who could have been treated in primary care could have been identified on initial triage in the ED, researchers applied an algorithm to nearly 35,000 records, each representing a unique ED visit, and compared presenting complaints to discharge diagnoses to identify all “primary care-treatable” visits. Results appeared in the March 20 Journal of the American Medical Association.

The study found that discharge diagnoses were not easily determined by presenting complaints. The primary care-treatable patients (who made up 6.3% [95% CI, 5.8% to 6.7%] of the total ED population) presented with the same complaints seen for 88.7% (95% CI, 88.1% to 89.4%) of all ED visits.

A total of 11.1% (95% CI, 9.3% to 13.0%) of these visits were identified at triage as needing immediate or emergency care, and 12.5% (95% CI, 11.8% to 14.3%) required hospital admission. Among admitted patients, 11.2% (95% CI, 9.5% to 12.9%) went to a critical care unit, 22.9% (95% CI, 18.4% to 27.4%) required step-down or telemetry monitoring, 3.4% (95% CI, 2.5% to 4.3%) required the operating room, and 7.0% (95% CI, 5.7% to 8.4%) were admitted to an observation unit.

Also, 3.7% (95% CI, 3.4% to 4.1%) of patients had been seen in the same ED within the last 72 hours, and 2.1% (95% CI, 1.7% to 2.5%) had been discharged from a hospital within the past seven days.

Further complicating matters was that 79.7% of patients with a non-emergency complaint (95% CI, 78.2% to 81.3%) had at least one abnormal triage vital sign recorded:

  • respiratory rate (61.8%; 95% CI, 59.9% to 63.8%),
  • blood pressure (34.2%; 95% CI, 32.7% to 35.8%),
  • abnormal heart rate (21.8%; 95% CI, 20.8% to 22.8%)
  • hypoxia (6.6%; 95% CI, 5.3% to 7.9%), or
  • hypo- or hyperthermia (6.1%; 95% CI, 5.5% to 6.7).

It may not be possible to accurately identify emergency visits that could have been treated by primary care instead in order to limit or deny payments for these visits, the researchers concluded.

The researchers wrote, “Attempting to discourage patients from using the ED based on the likelihood that they would have nonemergency diagnoses risks sending away patients who require emergency care. The majority of Medicaid patients, who stand to be disproportionately affected by such policies, visit the ED for urgent or more serious problems.”