Treatment of trainees, admission patterns, and more

Summaries from ACP Hospitalist Weekly.

More research needed to assess programs addressing mistreatment of medical trainees

Mistreatment of medical trainees is a known problem, but existing research on programs to address the issue is sparse and generally of low quality, according to a recent systematic review.

Researchers reviewed more than 3,300 articles but found only 10 peer-reviewed studies that presented outcomes of programs to decrease the incidence of mistreatment of medical trainees in academic medical centers. Seven programs were in the U.S., and the other three were implemented in Canada, the United Kingdom, and Australia. Results of the descriptive review were published in the July 2018 issue of JAMA Network Open.

The most common format of the programs was a combination of lectures, workshops, and seminars. The overall quality of studies was low, and the outcomes reported were often limited to participant survey data. All studies assessed participant satisfaction, and seven studies also included the frequency of mistreatment reports by surveys or official reporting channels.

Overall, participant satisfaction was high across studies, but there were minimal changes in mistreatment reports in the studies that assessed pre- and postintervention data. “The programs are very diverse in concept, content, and outcome measures, preventing any real conclusions regarding best practices for future educators wishing to address this problem,” the study authors wrote.

The authors noted limitations to the review, such as the possibility that their literature search may have omitted relevant studies and that publication bias may affect the reporting of studies with negative results. They added that they looked exclusively at reports of programs to prevent mistreatment of trainees, although programs targeting other professional interactions (e.g., between physicians and nurses) may mimic the student-teacher relationship.

Best practices for traditional research (e.g., blinding and randomization) are neither feasible nor appropriate for this problem, an accompanying editorial comment noted. While the study authors suggested that theoretical frameworks to support the rationale for interventions may enhance the quality of future studies, the editorialists cautioned that frameworks derived from trainees' perceptions of mistreatment must be validated before programs are implemented.

“Establishing a shared mental model about what is and is not mistreatment among teachers and learners is a necessary component when planning research to examine the effectiveness of programs, but is insufficient to bring about change in behavior or the learning environment,” the editorialists wrote. Next steps to address the problem should include development of additional outcome measures and a national collaborative research network, as well as financial support for high-quality, multicenter studies, they added.

Inpatient medicine services see wide variety of conditions in similar pattern across hospitals

The most common discharge diagnoses are similar across general internal medicine (GIM) services at different hospitals, a recent study found.

The retrospective cross-sectional study included all patients admitted to an inpatient GIM service at any of seven hospitals in Toronto, Canada, and discharged between April 1, 2010, and March 31, 2015. Hospital administrative data were used to identify diagnoses (which were categorized using the Clinical Classifications Software tool) and costs associated with the 148,442 admissions. Results were published by the Journal of General Internal Medicine on July 27, 2018 and in the November 2018 print issue.

Image by Getty Images
Image by Getty Images

The most common primary discharge diagnoses were heart failure (5.1%), pneumonia (5.0%), urinary tract infection (4.6%), chronic obstructive pulmonary disease (4.5%), and stroke (4.4%). Looking at the 20 most common conditions, the researchers found a significant correlation across hospitals, with at least 15 of them being among the top 20 at each hospital. No single condition was responsible for more than 5.1% of overall admissions or more than 7.9% of any individual hospital's admissions. The highest-cost conditions were stroke (median cost, $7,122; interquartile range [IQR], $5,587 to $12,354; total cost, $94,199,422; 6.0% of all costs) and the grouping of delirium, dementia, and cognitive disorders (median cost, $12,831; IQR, $9,539 to $17,509; total cost, $77,372,541; 4.9% of all costs).

The 10 most common conditions accounted for 36.2% of hospitalizations, which is much lower than the 83.3% and 72.6% that other studies have found for emergency general surgery and emergency ICU admissions, respectively, the authors said. Other than those 10, the discharge diagnoses represented 223 different condition categories in the Clinical Classifications Software, the authors noted.

“The diversity of conditions cared for in GIM may be challenging for healthcare delivery and quality improvement. Initiatives that cut across individual diseases to address processes of care, patient experience, and functional outcomes may be more relevant to a greater proportion of the GIM population than disease-specific efforts,” they said.

However, disease-specific approaches will continue to also be important to improving health care, and the study's findings about the mostly common and costly conditions could inform these approaches, the authors added. The study was limited by its relatively small sample and use of ICD-10 codes. The findings are also not necessarily generalizable to smaller nonteaching hospitals, they said.

Peripheral IV catheter failure rates similar, regardless of dressing or securement device

Specialized devices and dressings didn't significantly reduce rates of peripheral IV catheter (PIVC) failure, according to a recent study.

The trial was conducted in two hospitals in Queensland, Australia. Adult patients who were expected to require a PIVC for at least 24 hours were randomized to receive tissue adhesive with polyurethane dressing (n=446), bordered polyurethane dressing (n=454), a securement device with polyurethane dressing (n=453), or the control method, polyurethane dressing (n=454). Some patients ended up not requiring a PIVC, so the intention-to-treat population totaled 1,697 patients. Results were published online by The Lancet on July 26, 2018, and in print on Aug. 4, 2018.

The study's primary outcome of all-cause PIVC failure (a composite of complete dislodgement, occlusion, phlebitis, and primary bloodstream infection or local infection) occurred in 41% of patients. Rates of failure were similar between groups: 43% in the polyurethane group, 41% in the securement device with polyurethane group (absolute risk difference [RD], −1.2%; 95% CI, −7.9% to 5.4%; P=0.73), 40% in the bordered polyurethane group (RD, −2.7%; 95% CI, −9.3% to 3.9%; P=0.44), and 38% in the tissue adhesive with polyurethane group (RD, −4.5%; 95% CI, −11.1% to 2.1%; P=0.19). Skin adverse events occurred in 17 patients in the tissue adhesive with polyurethane group, eight patients in the securement device with polyurethane group, seven patients in the polyurethane group, and two patients in the bordered polyurethane group.

Total costs of the interventions did not differ significantly between groups, although the authors noted that if costs for infection were excluded, the mean cost per patient would be significantly lower for polyurethane than the other options.

“Two billion PIVCs are used globally each year, thus using polyurethane for all PIVC insertions instead of other securement devices and dressings could save $3.4–13.7 billion per year in products, staff time, and responses to PIVC failure (excluding infections),” they wrote.

The results suggested some potential benefit from tissue adhesive, but many patients who received it required additional dressing reinforcement (as did 67% of the overall study patient population), the authors said.

“When durable dressings are identified, tissue adhesive might be a useful adjunct in the future,” they wrote. “Innovations to achieve effective, durable dressings and securements, and randomised controlled trials assessing their effectiveness are urgently needed.” In the interim, cost should be the primary factor in the choice of a method to secure PIVCs, they said, noting that the CDC considers the optimal dressing and securement unresolved.

New algorithm may help guide empiric therapy for patients with any type of pneumonia

A single algorithm based on risk factors for multidrug-resistant pathogens, rather than site of pneumonia acquisition, may help guide empiric therapy for all patients with pneumonia, a recent study suggested.

From November 2013 to April 2017, researchers prospectively applied a new therapeutic algorithm to a cohort of 1,089 patients with pneumonia at 12 hospitals in Japan: 656 with community-acquired pneumonia (CAP), 238 with health care-associated pneumonia (HCAP), 140 with hospital-acquired pneumonia (HAP), and 55 with ventilator-associated pneumonia (VAP). All patients were hospitalized with radiographically confirmed pneumonia with appropriate clinical findings.

The algorithm classified patients into four groups based on severity of illness (i.e., need for mechanical ventilation or ICU admission) and the presence of other risk factors for multidrug-resistant pathogens. The six risk factors included antibiotic therapy in the past 180 days, poor functional status (Barthel Index <50 or performance status ≥3), hospitalization for more than two days in the past 90 days, occurrence five days or more after admission to an acute hospital, hemodialysis, and immunosuppression.

Patients with zero or one risk factor (groups 1 and 3) received therapy for CAP (a beta-lactam in combination with a macrolide). Those with two or more risk factors (groups 2 and 4) received HAP therapy (two- or three-drug regimen including an anti-pseudomonal beta-lactam in combination with a quinolone or aminoglycoside, plus either optional linezolid or vancomycin).

Results were published online on Aug. 1 by Clinical Infectious Diseases.

Overall, 898 (82.5%) patients were treated according to the algorithm. When the recommended therapy was followed, it led to an inappropriate choice in only 4.3% of patients. The frequency of multidrug-resistant pathogens varied across pneumonia types (VAP, 50.9%; HAP, 27.9%; HCAP, 10.9%; and CAP, 5.2%). Patients with two or more risk factors had multidrug-resistant pathogens more often than those with zero or one risk factor (25.8% vs. 5.3%; P<0.001).

The 30-day mortality rate was 7% for all patients (VAP, 18.2%; HAP, 13.6%; HCAP, 6.7%; and CAP, 4.7%). Mortality rates were lower in those with zero or one risk factor than in those with two or more risk factors (4.5% vs. 12.5%; P<0.001). In a multivariate logistic regression analysis, hypotension (systolic blood pressure ≤90 mm Hg), inappropriate therapy, and five risk factors (age ≥75 years, hematocrit <30%, albumin level <3.0 g/dL, blood urea nitrogen level ≥21 mg/dL, and chronic liver disease) were significantly correlated with 30-day mortality, whereas pneumonia type was not.

The authors noted limitations of the study, such as the need to apply the algorithm in countries other than Japan and the fact that the algorithm does not include therapy for viral infections even though the cohort included patients with viral infection and suspected bacterial co-infection. They added that the application of the algorithm may be limited for terminally ill patients who do not receive mechanical ventilation or ICU admission.

The authors added that once the algorithm is verified in other clinical settings, it could be supplemented with hospital-specific antibiograms to optimize therapy for patients with HAP and VAP. “Use of our algorithm has the possibility to eliminate excessive use of antibiotics and simplify pneumonia treatment, while leading to a high rate of appropriate empiric therapy with an associated good outcome,” they wrote.