In the News

Interventions make discharges more timely, statins help with delirium in critically ill.

Series of interventions increased percentage of timely discharges

A series of interventions enabled hospitalists to increase the percentage of patients who were discharged before noon from 11% to 38%, a recent study found.

Researchers implemented the intervention at Langone Medical Center's Tisch Hospital in New York City on 2 acute care units where hospitalists led team-based care. While interdisciplinary rounds had always occurred in the morning, the intervention added a set of rounds at 3 p.m. to identify the next day's discharge-before-noon (DBN) patients. Staff members were trained to use a discharge checklist on DBN patients during the afternoon rounds. A website was created for care managers to log expected DBNs after the 3 p.m. rounds; the site then generated a daily automated email at 4:30 p.m. for staff who needed to know about the next day's DBN (e.g., hospitalists, nurses, bed management, residents, etc).

The DBN patients' records then were reviewed on the morning of discharge for any relevant overnight notes. Prizes were awarded each month in the first 3 months of the intervention for hitting DBN targets, and daily feedback was provided throughout the 13-month intervention by way of a poster with DBN statistics in staff areas. The initial goal was 30% DBN patients, but this goal increased to 40% during the intervention period.

The pre-intervention, monthly baseline DBN was 11%; post-intervention, the monthly DBN was 38% (P=0.0002). The observed-to-expected length of stay (O/E LOS)—i.e., the expected LOS divided by observed LOS—fell from 1.06 at baseline to 0.96 after the intervention (P=0.0001). The 30-day readmission rate fell from 14.3% at baseline to 13.1% during the intervention period, but this wasn't significant and could reflect other initiatives ongoing at the hospital, the researchers said. The results of this study intervention were published in the April Journal of Hospital Medicine.

While they were unable to isolate the individual effects of each element of the intervention, the authors said they thought the most important parts were the kickoff event to apprise staff members of their roles; daily real-time feedback via unit boards; and a standardized form of communication for DBNs. They also stressed that plans must be made, and patient and family members alerted, the day before discharge for a DBN initiative to be successful. “Our study demonstrates that increased timely discharge is an achievable and sustainable goal for medical centers,” the authors concluded. Such interventions may help alleviate admission bottlenecks in the emergency department and the longer lengths of stay that are thought to result from late afternoon discharges, they said.

Statins may help delirium in critically ill patients, study finds

Statin treatment may be associated with lower delirium risk in critically ill patients, according to a recent study.

Researchers in the United Kingdom performed a prospective cohort study of data from consecutive patients treated in a medical/surgical critical care unit between Aug. 1, 2011, and Feb. 29, 2012. The study's objective was to evaluate whether patients receiving statins had a lower risk for delirium than those not receiving statins. The Confusion Assessment Method for ICU (CAM-ICU) assessed the number of days on which each patient was considered delirium-free during his or her ICU stay. Other outcome measures were daily statin administration and serum levels of C-reactive protein (CRP). The study results were published in the March 15 American Journal of Respiratory and Critical Care Medicine.

Overall, 470 patients were included in the study, 151 of whom took statins. No patients received a new statin prescription; all patients who took statins in the ICU had also taken them before ICU admission. Patients who received statins were more likely than those who did not to be older and to have lower median levels of CRP. A total of 167 patients had delirium at least once during their ICU stay, and of this group, 44 had delirium for their entire stay. Median duration of delirium was 2 days. In a random-effects multivariable logistic regression model, statins taken the previous night were associated with a delirium-free assessment (odds ratio, 2.28; P<0.05) and a lower CRP level (beta coefficient, -0.52; P<0.01) the next day. When the researchers controlled for CRP level, however, the association between statin use and delirium-free assessment became nonsignificant (odds ratio, 1.56; P=0.32). Odds of being delirium- and coma-free increased for every day a patient continued to take a statin (odds ratio, 1.39; P<0.001).

The authors hypothesized that the anti-inflammatory effect of statins may be related to a decrease in delirium risk. They noted that their study involved only a single center, was observational, and looked only at statins given in the ICU, not before admission. They also pointed out that statins are more likely to be administered as a patient improves, which could have affected their results, and that no information on individual statin doses or on sedation regimens was available. Also, they said, most patients received simvastatin, and it isn't clear whether one statin might be better than others. However, they concluded that their results indicate a potentially beneficial effect of statins on delirium in ICU patients and suggest that patients taking statins before ICU admission should continue them during admission, “albeit with appropriate safety monitoring.” A phase 2 randomized, placebo-controlled trial in critically ill ventilated patients is currently under way to further examine whether daily statins decrease delirium risk.

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