Standardized rounds, antibiotics and acute kidney injury, and more

Summaries from ACP Hospitalist Weekly.

Standardized bedside attending rounds increased patient satisfaction

Patient satisfaction increased when internal medicine teams adopted standardized bedside attending rounds, a recent cluster randomized trial found.

Eight teams (composed of an attending physician, a senior resident, two interns, and a third- and/or fourth-year medical student) with a total average daily census of 80 to 90 patients were included in the one-hospital trial. Researchers randomized four of the teams to adhere to a set of five recommendations: huddling to establish the rounding schedule and priorities, conducting bedside rounds, integrating bedside nurses, completing real-time order entry using bedside computers, and updating the whiteboard in each patient's room with care plan information.

The primary outcome was patient satisfaction with attending rounds, and secondary outcomes were perceived and actual duration of attending rounds and attending/trainee satisfaction. Results of the trial, which was conducted from Sept. 3 to Nov. 27, 2013, were published in the March Journal of Hospital Medicine.

Study investigators trained attendings and trainees in the intervention arm on the recommended practices, and those in the control arm continued rounding practices as usual. Trained observers recorded 241 attending rounds involving 1,855 patient encounters in the intervention arm and 264 rounds involving 1,903 encounters in the control arm. Intervention teams adhered most to the pre-rounds huddle (78.1%) and least to whiteboard use (29.9%).

Patients in the intervention arm (n=146) and in the control arm (n=141) completed satisfaction survey questions on a five-point Likert scale that asked about their involvement in decision making, quality of communication with the team, and perception of the team's caring. Those in the intervention arm reported significantly higher satisfaction with rounds (P=0.011) and felt more cared for by their team (P=0.031) than those in the control arm, but there were no significant differences between groups in the other domains.

The intervention shortened total duration of attending rounds by an average of eight minutes (143 vs. 151 minutes, P=0.052) and the time spent per patient by an average of four minutes (19 vs. 23 minutes, P<0.001). However, trainees in the intervention arm perceived attending rounds to last longer (mean estimated time, 167 vs. 152 minutes, P<0.001).

Attendings in the intervention arm were significantly more likely to report an appropriate level of patient involvement (P=0.001) and nurse involvement (P=0.032) than those in the control arm. Trainees in the intervention arm reported significantly lower satisfaction with rounds compared to those in the control arm (P=0.046), reporting less autonomy, efficiency, and teaching.

The reduced trainee satisfaction with the intervention may be related to time pressures to complete their work or the potential perception of decreased autonomy and less teaching, the study authors noted. “Attending physicians may mitigate the risk of compromising trainee autonomy by allowing the trainee to speak first, ensuring the trainee is positioned closer to, and at eye level with, the patient, and redirecting patient questions to the trainee as appropriate,” they suggested. Limitations of the study include its single-center design and potential lack of generalizability to other settings, as well as the exclusion of non-English-speaking patients.

Vancomycin and piperacillin-tazobactam combo associated with increased AKI risk

Combination therapy with vancomycin and piperacillin-tazobactam is associated with significantly higher risk for acute kidney injury (AKI) than either drug alone, a recent study found.

The retrospective cohort analysis included adult patients who received one or both drugs while admitted to one academic medical center between Sept. 1, 2010, and Aug. 31, 2014. None of the patients had renal disease at baseline, and they were followed until hospital discharge. The study's definition of AKI was based on the RIFLE (Risk, Injury, Failure, Loss, End-stage) criteria, which classifies a decrease in estimated glomerular filtration rate of 25%-50% as risk, 50%-75% as injury, and greater than 75% as failure (all of which the study considered AKI). Results were published in the February Journal of Hospital Medicine.

Photo by Thinkstock
Photo by Thinkstock.

Of the 11,650 studied patients, 1,647 (14.1%) developed AKI. AKI was significantly more common in the patients on combination therapy (21%) than in those on vancomycin alone (8.3%) or piperacillin-tazobactam alone (7.8%). After adjustment, combination therapy was independently associated with higher AKI risk than either drug alone (odds ratio vs. vancomycin, 2.03 [95% CI, 1.74 to 2.39]; odds ratio vs. piperacillin-tazobactam, 2.31 [95% CI, 1.97 to 2.71]).

The development of AKI after vancomycin therapy “is a well-characterized adverse effect,” but the association with piperacillin-tazobactam is less understood, according the study authors. There also appears to be an additive effect when these drugs are combined, the mechanisms for which are unknown. “These findings demonstrate the need for judicious use of combination therapy and strengthen the need for antimicrobial de-escalation when appropriate to avoid deleterious effects,” the authors wrote.

The study also emphasizes the need for vigilance to detect and intervene early in AKI, noted an accompanying editorial. The editorialists offered a number of other suggestions for improving care related to AKI, including that the condition be documented in the discharge summary and explained to patients. They also recommended referring high-risk AKI patients to nephrology after discharge and consulting nephrologists about medication management of hospitalized patients with chronic kidney disease.

Death soon after ED discharge appears common in Medicare beneficiaries

A substantial proportion of Medicare beneficiaries die soon after discharge from the ED, although it is unclear how many of these deaths are preventable, a recent study found.

Researchers performed a retrospective cohort study using Medicare claims data for ED visits from 2007 to 2012 to examine the incidence of early death after ED discharge and determine potential reasons for variation in risk. The study excluded patients living in nursing facilities, those ages 90 and older, those receiving palliative or hospice care, and those who had been diagnosed with a life-limiting illness. The main outcome measure was death within seven days of ED discharge in all patients except those who were transferred or those who were admitted as inpatients. Results were published online Feb. 1 by BMJ.

From 2007 to 2012, 10,093,678 patients were discharged from the ED, and of these, 0.12%, or 12,375, died within seven days. Patients' mean age at death was 69 years. The most common causes of death as listed on death certificates were atherosclerotic heart disease (13.6%), myocardial infarction (10.3%), and chronic obstructive pulmonary disease (9.6%). Hospitals that admitted fewer patients from the ED had the highest rates of early death versus hospitals that admitted the most patients (0.27% vs. 0.08% for the lowest fifth vs. the highest fifth), although hospitals with lower admission rates appeared to serve healthier populations in general, as evidenced by overall seven-day mortality rates of all patients who came through the ED (0.3% vs. 1.0% for the lowest vs. the highest fifth). Higher patient volume and higher visit charges were significantly associated with fewer deaths. ED visits with diagnoses of altered mental status (risk ratio, 4.4; 95% CI, 3.8 to 5.1), dyspnea (risk ratio, 3.1; 95% CI, 2.9 to 3.4), and malaise or fatigue (risk ratio, 3.0; 95% CI, 2.9 to 3.7) were more likely to be associated with early death than ED visits with other diagnoses.

The authors noted that they could not determine which early deaths were preventable, and they noted that these data should not be viewed as evidence of error, since some of the variation could be linked to geographic and socioeconomic issues. The excluded diagnoses could also have been overly broad, among other limitations. However, they concluded that based on their data, many Medicare beneficiaries die soon after ED discharge even without a history of life-limiting illnesses. “Hospitals with low admission rates and low patient volumes, and patients with high risk diagnoses at discharge, could represent targets for clinical research and quality improvement efforts,” the researchers wrote. They called for additional studies to examine systems of care, presenting symptoms, and the value of hospital admission.