Interns' days, patients' hands

Summaries from ACP Hospitalist Weekly.

Internal medicine interns spend only 13% of workday on direct patient care

First-year internal medicine residents spend an average of two-thirds of their workday on indirect patient care, often while multitasking, and only 13% directly caring for patients, a recent study found.

Researchers conducted a direct observational secondary analysis of the individualized Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial, which used a cluster-randomized design to compare different duty-hour policies. From March 10 to May 31, 2016, observers collected time-motion data from a total of 194 weekday shifts at six U.S. internal medicine programs. Results were published online on April 15 by JAMA Internal Medicine.

A total of 80 interns (55% men; mean age, 28.7 years) were observed for 2,173 hours. Overall, an average of 15.9 hours of a 24-hour period (66%) was spent on indirect patient care, which was mostly composed of interactions with patients' medical records or documentation (mean, 10.3 hours [43%]). An average of 3.0 hours (13%) was spent directly caring for patients, and an average of 1.8 hours (7%) was spent on education. These patterns were consistent across morning, afternoon, evening, and night.

Interns were frequent multitaskers, the study found. Direct patient care and education often occurred when interns were also performing indirect patient care. On average, multitasking with two or more indirect patient care activities occurred for 3.8 hours (16%) of the workday.

The study was limited to internal medicine interns, and the activities of interns in other specialties are likely to be different, the study authors noted. Other limitations include a potential lack of generalizability to other training programs and the fact that interns were observed only during general medical inpatient rotations.

If one believes that the best way to care for patients and learn from them is personal contact, then one might conclude that the findings are a problem, the authors noted. “A more agnostic view is that even if face-to-face engagement is essential, more may not be necessary given that so much of patient care now occurs in teams, is informed by diagnostic test reports, and is mediated through the work of others,” they wrote.

As recently as the 1990s, interns spent about 25% of their workday face-to-face with patients, an accompanying editorial noted. While the finding that modern interns spend more time with computers than direct patient care is not novel, “The present time-motion study shows that, like it or not, internal medicine is now indeed a trade practiced before a computer screen,” the editorialists wrote.

Newly admitted patients' hands commonly contaminated with multidrug-resistant bacteria

Contamination of patient hands with multidrug-resistant organisms is common in the hospital and correlates with contamination of high-touch room surfaces, potentially putting other patients at risk of pathogen transmission, a recent study found.

Researchers recruited general medicine patients from two hospitals within 24 hours of room arrival and followed them prospectively using microbial surveillance of their nares, their dominant hands, and six high-touch environment surfaces: bed control/bed rail, call button/television remote, bedside tray table top, phone, toilet seat, and bathroom doorknob. Patients were sampled on admission, day 3, day 7, and weekly thereafter until discharge.

The researchers also used molecular typing to assess the relatedness of paired samples of methicillin-resistant Staphylococcus aureus (MRSA) isolated from the patients' hands and room surfaces. Results were published online on April 13 by Clinical Infectious Diseases.

A total of 399 patients (mean age, 60.8 years; 49% men) were followed for 710 visits. At baseline, 56 (14.0%) patients were colonized with a multidrug-resistant organism: 40 (10.0%) on their hands, 30 (7.5%) in their nares, and 14 (3.5%) at both anatomic sites. At baseline (within 24 hours of admission), 29% of sampled surfaces of patient rooms harbored a multidrug-resistant organism, suggesting that patients were often admitted with such organisms and that there was a rapid change in the microbial milieu in patients' rooms after admission.

Of 225 patients with at least two study visits, 14 (6.2%) patients newly acquired a multidrug-resistant organism on their hands during hospitalization. In addition, 49 (21.8%) patient rooms newly acquired a multidrug-resistant organism during the stay. New acquisition of a multidrug-resistant organism occurred in patients at a rate of 24.6 per 1,000 patient-days and in rooms at a rate of 58.6 per 1,000 patient-days. Typing showed a high correlation between MRSA on patients' hands and room surfaces.

Limitations of the study include the fact that cultures of high-touch surfaces were not performed prior to room occupancy, as patients were recruited after admission, the study authors noted. In addition, they could not determine whether a patient or health care professional contaminated the high-touch room surfaces, or whether patient-to-patient transmission of pathogens occurred.

Although the burden of infection prevention has largely been on health care professionals, the findings suggest that patient hands play a crucial role in pathogen transmission in the hospital, the authors concluded. “Thus, patient hand hygiene protocols should be implemented and tested for their ability to reduce environmental contamination, pathogen transmission, and healthcare-associated infections as well as to increase meaningful patient engagement in infection prevention,” they wrote.

ED visits related to cannabis increased after legalization, most related to inhaled form

Visits to the ED attributable to inhaled cannabis were more frequent than edible-related visits at an urban academic hospital in Colorado following marijuana legalization, although acute psychiatric events and cardiovascular symptoms were more common with edible exposure, a retrospective study found.

Researchers reviewed health records to assess the characteristics of adult ED visits related to cannabis exposure between Jan. 1, 2012, and Dec. 31, 2016. Results were published online on March 26 by Annals of Internal Medicine and appeared in the April 16 issue.

Image by Getty Images
Image by Getty Images

Overall, there were 9,973 ED visits with an ICD-9-CM or ICD-10-CM code for cannabis use, and 2,567 (25.7%) were at least partially attributable to cannabis. The frequency of visits attributable to any form of cannabis increased more than threefold during the study period, most drastically from 2015 to 2016. Of visits attributable to cannabis, 238 (9.3%) were related to edible exposure, with the remainder considered to be related to inhaled cannabis. Patients who inhaled cannabis were significantly more likely to be admitted to the hospital after the ED visit than those who ingested cannabis (32.9% vs. 18.9%; P<0.001).

Reasons for the ED visits differed between the two routes of exposure. Visits attributable to inhaled cannabis were more likely to be for cannabinoid hyperemesis syndrome (18.0% vs. 8.4%), whereas visits attributable to edible forms were more likely to be due to acute psychiatric symptoms (18.0% vs. 10.9%), intoxication (48% vs. 28%), and cardiovascular symptoms (8.0% vs. 3.1%). Edible cannabis accounted for only 0.32% of total cannabis sales (in kg of tetrahydrocannabinol [THC]) from 2014 to 2016, when recreational cannabis was legal, but made up 10.7% of cannabis-attributable ED visits at the hospital during this period. Therefore, the observed proportion of cannabis-attributable visits with edible exposure was about 33 times higher than expected (10.7% vs. 0.32%).

Limitations of the study include its retrospective design, with exposure data captured in large part through self-report and doses unable to be verified, the authors noted. In addition, data were limited to one hospital in one state, and there was no comparative community-based exposure cohort, they said. “Patients presenting to the ED clearly differ from the overall population of cannabis users, most of whom may use cannabis with no adverse effects,” the authors wrote.

Variability in oral THC absorption between individuals is considerable, which contributes to the unpredictability of drug effects and adverse outcomes, according to an accompanying editorial. “Some of this is due to the fat content of food ingested when THC is consumed. Because THC is highly lipophilic, fat increases its absorption, but it might also affect its first-pass metabolism in the liver,” the editorialists noted.

Overall, the study highlights the need for clinicians to screen for cannabis use and be aware of its potential adverse health consequences, which are not fully understood, the editorial said. “Research is needed not only to rigorously ascertain evidence about potential beneficial effects of cannabis but also to carefully characterize its potential negative effects,” the authors wrote.

Joint Commission offers safety briefing on drug diversion

About 10% of health care workers abuse drugs, and programs should be in place to prevent drug diversion, according to a new safety briefing from The Joint Commission.

Diversion of controlled substances can be difficult to detect and prevent without a comprehensive controlled substances diversion prevention program, the Commission stated. A major driver of drug diversion is the epidemic level of opioid abuse, and fentanyl is the most commonly diverted drug, as well as the leading driver of deaths due to opioid overdoses, according to the briefing.

“Experts believe that only a fraction of those who are diverting drugs are ever caught, despite clear signals—such as abnormal behaviors, altered physical appearance, and poor job performance,” it said. “Direct observation is vital to detecting diversion and may be the only way to identify an impaired colleague.”

The Joint Commission suggested that a surveillance program for drug diversion should focus on patterns and trends, including:

  • Controlled substances being removed without doctor's orders, for patients not assigned to the clinician, or for recently discharged or transferred patients.
  • Compromised product containers.
  • Substitute drugs being removed and administered while a controlled substance is diverted.
  • Verbal orders for controlled substances being created but not verified by the prescriber.

There are three essential components health care organizations need to consider when dealing with drug diversion: prevention, detection, and response, the safety briefing said.

  • Prevention: Health care facilities are required to have systems to guard against theft and diversion of controlled substances.
  • Detection: Health care facilities must initiate systems to facilitate early detection such as video monitoring of high-risk areas, active monitoring of pharmacy and dispensing record data, as well as staff who are aware of and alert to common behaviors and other signs of potential diversion activity.
  • Response: Appropriate response for staff should be “see something, say something.” At the institutional level, appropriate responses include establishing a just culture in which reporting drug diversion is encouraged.

“Detection of drug diversion is challenging, and even the best efforts have not yet achieved complete eradication of diversion,” the safety briefing said. “Patient and workplace safety require effective reliable safeguards to maintain the integrity of safe medication practices to protect against diversion. Diversion prevention requires continuous prioritization and active management to guard against complacency.”

Telemedicine ID consults reduced length of stay for patients with active infections

Implementation of telemedicine infectious disease consults for inpatients was associated with decreased length of stay, according to a recent study.

The infectious diseases division at one health network, based at an outpatient office at a main campus (hub hospital), began seeing inpatients with active infections at a 150-bed remote hospital via real-time interactive telemedicine consultations. Researchers assessed the impact of the consults from February 2013 to February 2014 by performing a manual retrospective chart review to evaluate postintervention changes in length of stay, antibiotic usage, and incidence of relapse (defined as either 30-day readmission with any infection or documentation of the same infection recurring within 90 days of discharge). Results were published on April 19 by Clinical Infectious Diseases.

Overall, 244 patients (mean age, 63 years) received an infectious disease consultation in person, via telemedicine, or both at the remote hospital. Before the intervention (February 2011 to February 2013), 73 of 73 patients were transferred to the hub hospital and seen by infectious disease specialists. After telemedicine consults were implemented, 171 patients received a consult and only 14 (8.2%) of them were transferred.

Length of stay decreased at both facilities after telemedicine consult became available (P=0.0001). The median number of days that patients received antibiotics decreased in the telemedicine group (median, 15; interquartile range [IQR], 9 to 25) compared to the preintervention group (median, 19; IQR, 11 to 28), although this was not a significant decrease (P=0.0770). There was no significant difference in relapse rates, although data were lacking because of loss to follow-up. In addition, the average antibiotic cost per hospitalized patient-day was $14.53 in 2012 compared to $11.25 in 2014.

Limitations of the study include its small and heterogeneous patient sample and the fact that some data were missing due to loss to follow-up, the authors noted. Nonetheless, “The reduction of antibiotic days and observed decrease in antibiotic cost suggest that [infectious disease] consultation through telemedicine offered an antibiotic stewardship effect, which serves as a relatively direct route of cost savings for the remote hospital,” they wrote.