EVALI, rapid response, and more

Research summaries from ACP Hospitalist Weekly.

Chronic conditions were common among inpatients who died of EVALI

While the clinical presentations and outcomes of patients who survived electronic cigarette or vaping product use-associated lung injury (EVALI) have been well described, a recent study looked at data from patients who died of the condition.

CDC researchers compared the characteristics of patients with fatal cases of EVALI and those of patients who recovered from the condition. They analyzed EVALI cases reported by health departments to the CDC, including data from medical-records abstractions and patient interviews. They also presented three case reports of patients who died of EVALI to show the clinical characteristics common among such patients. Results were published on April 23 by the New England Journal of Medicine.

As of Jan. 7, 2,558 nonfatal cases of EVALI in hospitalized patients from 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands and 60 fatal cases in patients from 27 states and the District of Columbia had been reported to the CDC. Among patients with data available on vaping product use, most reported using tetrahydrocannabinol-containing products and/or nicotine-containing products. Among those with data available on race/ethnicity and sex, most patients were non-Hispanic white (39 of 49 fatal cases [80%] and 1,104 of 1,818 nonfatal cases [61%]) and men (32 of 60 fatal cases [53%] and 1,666 of 2,498 nonfatal cases [67%]). The median age was 51 years (range, 15 to 75 years) among those with fatal cases and 24 years (range, 13 to 85 years) among those with nonfatal cases.

Image by Getty Images
Image by Getty Images

The proportion of fatal cases was higher among those ages 35 years and older (44 of 60 [73%]) than among those younger than age 35 years. Among patients with a medical history available, a higher proportion of those with fatal cases than those with nonfatal cases had a history of asthma (13 of 57 [23%] vs. 102 of 1,297 [8%]), cardiac disease (26 of 55 [47%] vs. 115 of 1,169 [10%]), or a mental health condition (32 of 49 [65%] vs. 575 of 1,398 [41%]). About half of patients with fatal cases had obesity (26 of 50 [52%]) and were seen in an outpatient setting before hospitalization or death (25 of 54 [46%]). The three case reports of patients who died of EVALI focused on a patient with multiple pre-existing medical conditions, a patient with recrudescence of symptoms, and a patient who received no glucocorticoids during initial hospitalization.

Limitations of the study include the fact many patients had pre-existing medical conditions that may have contributed to deaths classified as fatal cases of EVALI and that some fatal cases may have been missed, the study authors noted. In addition, “Eight patients had been discharged from a hospital before they died, which suggests that there may be opportunities to review stability before discharge, to tailor messaging and interventions more toward the avoidance of e-cigarette, or vaping, products, to communicate the importance of adherence to a glucocorticoid-tapering schedule, to enhance coordinated postdischarge care, and to identify worsening symptoms with timely follow-up after discharge,” they said.

Although the outbreak has lessened in intensity since its recognition in August 2019, it is unlikely that vaping-induced lung disease is gone for good, an accompanying editorial said. “Although the EVALI crisis may now have faded, millions of e-cigarette users still have virtually no protection against the potential harms from the thousands of largely unregulated e-cigarette devices and liquids on the market,” the editorialists wrote.

EVALI outbreak in California showed similar outcomes, vaping behaviors as other states

A recent case series from California echoed previous reports of the e-cigarette, or vaping, product use-associated lung injury (EVALI) outbreak, including the predominant use of tetrahydrocannabinol (THC)-containing products obtained from informal sources.

The report included epidemiologic and laboratory data from 160 hospitalized patients with EVALI reported by treating clinicians to the California Department of Public Health from Aug. 7 through Nov. 8, 2019. Researchers conducted standardized patient interviews to assess vaping products used, frequency of use, and method of product acquisition. In addition, a subset of patients provided their vaping products, which researchers tested for active ingredients and other substances. The researchers also reviewed medical records to assess demographic and clinical characteristics, level of care, and outcomes of hospitalization. Results were published online on March 6 by JAMA Internal Medicine.

Among 160 patients with EVALI, 99 (62%) were male, and the median age was 27 years (range, 14 to 70 years). Of 156 patients with medical record data available, 71 (46%) were admitted to an ICU, and 46 (29%) required mechanical ventilation. Four patients died in the hospital. Of 86 patients interviewed, 71 (83%) reported vaping THC-containing products, 27 (31%) reported vaping exclusively THC-containing products, 36 (43%) reported vaping cannabidiol-containing products, and 39 (47%) reported vaping nicotine-containing products. Thirty patients (35%) reported vaping five or more times daily, and 63 (73%) reported vaping at least once per day. Sixty-five of 87 (75%) THC-containing products were reported as obtained from informal sources (e.g., friends, acquaintances, unlicensed retailers). Of 87 vaping products tested from 24 patients, 49 (56%) contained THC. Vitamin E or vitamin E acetate was found in 41 (84%) of the THC-containing products and in none of the nicotine products.

The case series was limited by patients' self-reporting of vaping practices and the relatively small percentage of patients who were interviewed, among other limitations, the study authors noted. The report, which seems to be the first to describe EVALI cases in a state with a legal recreational cannabis market, appears to confirm patterns of clinical findings and vaping practices in other states and nationally, they said.

“These findings underscore the importance for all clinicians, including outpatient health care providers, to consider EVALI in patients with a history of vaping who present with typical findings of infection, as well as monitor their clinical course and respiratory status closely for decompensation, in accordance with CDC guidance,” they wrote.

Rapid response on the wards linked to unplanned ICU admissions

Patients admitted to the ICU from the wards after review by a rapid response team (RRT) have more chronic and acute illness and make up the majority of ward-based ICU admissions, a recent study in Australia and New Zealand found.

Researchers conducted a multicenter retrospective cohort study at 178 ICUs in both countries from 2012 to 2017 to determine the proportion of unplanned ICU admissions from hospital wards that occurred after RRT review and compare them with those that did not. The primary outcome measures were the proportion of unplanned ICU admissions associated with a RRT review, differences in baseline and ICU admission characteristics between patients admitted with or without RRT review, and differences in ICU therapies and outcomes. The study results were published April 16 by Critical Care Medicine and appeared in the July issue.

Overall, there were 97,181 unplanned ICU admissions from the wards during the study period, and of these, 55,084 (56.7%) received previous RRT review. Patients admitted to the ICU after RRT review were older (65.4 years vs. 63.3 years), had higher Acute Physiology and Chronic Health Evaluation III (APACHE III) scores (64.6 vs. 54.7), and were more likely to have limitations of medical treatment (13.1% vs. 8.5%) than those admitted without RRT review. (Limitations of treatment were defined as medical treatments constrained by medical futility or by patients' wishes.) Age, diagnosis at ICU admission, tertiary ICU status, and limitations of medical treatment had the strongest independent associations with ICU admission after RRT review (P<0.0001 for all comparisons). Patients admitted to the ICU after RRT review had longer median ICU and hospital stays (2.4 days vs. 2.1 days and 12.8 days vs. 10.8 days, respectively) and were more likely to die in the ICU (12.3% vs. 7.5%) and in the hospital (20.8% vs. 13.5%). After adjustment for illness severity and institution, the association between RRT review and length of stay remained but there was no increased risk for in-hospital death (adjusted odds ratio, 1.03; 95% CI, 0.98 to 1.07).

The researchers noted that their study was limited by its retrospective design and the lack of data on RRT structure and the number of RRT calls made at individual hospitals, among other factors. They concluded that patients needing unplanned ICU admission from the wards after RRT review were sicker and more likely to have sepsis and limitations of medical treatment than patients admitted without RRT review. However, while unadjusted outcomes were worse among the RRT group, mortality between groups was similar once the results were adjusted for illness severity. “Further research is needed to ascertain whether some ICU admissions were potentially avoidable, and to explore the role of sepsis in ward-based clinical deterioration,” the authors concluded.

Hospitalists, primary care clinicians favor EMR communication at discharge over other methods

Both primary care clinicians and hospitalists in a recent survey preferred to communicate with each other at discharge through direct messages in the electronic medical record (EMR).

Researchers surveyed 38 academic hospitalists and 63 primary care clinicians in the same safety-net hospital system to determine how each group wanted to communicate at discharge. Modes of communication surveyed were phone, email, fax, text messaging, or direct message via a shared EMR. Another survey examined which information clinicians preferred to communicate directly and challenges to and satisfaction with direct communication. Survey responses were analyzed using descriptive statistics. Semi-structured interviews were also conducted with six academic hospitalists and seven primary care clinicians, with participants recruited via email. The results were published April 2 by the Journal of General Internal Medicine.

Twenty-six academic hospitalists (50.7%) and 32 primary care clinicians working at outpatient clinics (68.4%) participated in the surveys. Overall, 75.9% of the primary care clinicians and 40% of the hospitalists were women. More than 50% of both groups reported that they were not satisfied with the current process for direct communication at discharge. Primary care clinicians preferred direct communication via an EMR message at discharge, and hospitalists preferred to receive both a direct EMR message and an email. Both primary care clinicians and hospitalists prioritized direct communication for high-risk medications, pending and follow-up tests, and high-risk patients about whom hospitalists were concerned. Communication priorities identified by both groups in interviews were ensuring patient safety, flagging patients with social challenges, and expressing concerns about patients that were based on clinical judgment.

Among other limitations, the study was conducted at a single center and had a small sample size, and the interviews were conducted by a hospitalist, which may have introduced social response bias, the authors noted. They concluded that hospitalists and primary care clinicians have similar concerns about continuity of care and believe direct communication at care transitions is required beyond the discharge summary. While improving direct communication is challenging, EMR messaging could be a solution and could allow for a closed loop if the recipient acknowledges the message, they said. “Discharge workflows should be developed to include direct communication between hospitalists and [primary care clinicians] for high-risk information that is critical for patient safety as they transition from the hospital back to the primary care setting,” the authors wrote.

1 in 5 patients had adverse event after ICU discharge to hospital ward

About one in five patients had an adverse event after discharge from the ICU to the hospital ward, and more than a third of such events may have been preventable, a study found.

Researchers looked at adverse events and associated factors and outcomes during transition from the ICU to a hospital ward after discharge from 10 adult medical-surgical ICUs at multiple centers in Canada from July 2014 to January 2016. To identify and classify adverse events, two ICU physicians independently reviewed progress and consultation notes documented in the medical record within seven days of ICU discharge date. Adverse event data were linked to patient characteristics, as well as ICU and ward physician surveys predicting each patient's risk of experiencing an adverse event, readmission, and in-hospital death. Results were published on April 17 by Critical Care Medicine and appeared in the July issue.

Image by Getty Images
Image by Getty Images

Of 451 patients included in the study, 84 (19%) experienced at least one adverse event, the majority (62%) within three days of transfer from the ICU to a hospital ward. Six percent of adverse events resulted in permanent disability or death. The most common adverse events were supportive care failures (e.g., falls, pressure ulcers, fluid and electrolyte disorders) and drug-related events. Most adverse events resulted only in symptoms (77%), and 36% were judged to have a greater than 50% chance of being preventable (reviewer agreement, 26%). Patients with adverse events were more likely to be readmitted to the ICU (odds ratio [OR], 5.5; 95% CI, 2.4 to 13.0; P<0.001), have a longer hospital stay (mean difference, 16.1 d; 95% CI, 8.4 to 23.7 d; P <0.001), and die in the hospital (OR, 4.6; 95% CI, 1.8 to 11.8; P=0.001) than those without an adverse event. In multivariable analyses, higher Charlson Comorbidity Index (OR, 1.24; 95% CI, 1.09 to 1.41), higher Acute Physiology and Chronic Health Evaluation II score on ICU discharge (OR, 1.07; 95% CI, 1.02 to 1.14), and being in an ICU with a 80% or more bed occupancy at 9 a.m. on the day of ICU discharge (OR, 1.97; 95% CI, 1.15 to 3.47) were independently associated with increased odds of experiencing an adverse event. ICU and ward physician predictions at the time of ICU discharge had low sensitivity and specificity for predicting adverse events, ICU readmissions, and in-hospital death.

Among other limitations, the evaluation of adverse events and their severity, preventability, and predictability can be subjective, the study authors noted. They added that most hospitals in the study were tertiary care teaching hospitals, so results may not be generalizable to nonteaching community hospitals where the same clinicians may care for patients in both the ICU and on the ward.

“Neither ICU nor ward physicians are able to reliably predict which patients will experience an AE [adverse event] after discharge from ICU to hospital ward,” the authors concluded. “Nevertheless, many AEs among critically ill patients are preventable, highlighting an important opportunity to improve the safety of care during the transition of care from the ICU to hospital ward.” Future research could evaluate the effect of post-ICU discharge follow-up programs, a longer length of ICU stay for patients at risk for adverse events, and step-down wards on the rate of adverse events, they said.

Treatment in disproportionately minority hospitals linked to increased sepsis mortality

Patients with sepsis who were treated in hospitals serving disproportionately more minority patients had significantly higher rates of in-hospital mortality than those treated in nonminority hospitals, a retrospective cohort analysis found.

Researchers used the National Inpatient Sample (NIS) to assess outcomes in adult patients with sepsis who were treated in disproportionately minority-serving U.S. hospitals from 2008 to 2014, defined as those with twice the relative minority patient population of the surrounding geographical mean. To assess the primary outcome of the association of treatment in a minority hospital with in-hospital mortality, they applied a multivariate model that was adjusted for severity of illness with a validated algorithm using administrative data. Results were published April 28 by Critical Care Medicine and appeared in the July issue.

Of about 4.2 million patients with sepsis identified in the NIS, 612,217 (14.5%) were treated at hospitals disproportionately serving the black community, and 181,141 (4.3%) were treated at hospitals disproportionately serving the Hispanic community. After multivariate analysis, treatment in a hospital serving more black patients was associated with a 4% higher risk of mortality compared to treatment in a nonminority hospital (odds ratio, 1.04; 95% CI, 1.03 to 1.05; P<0.01). Treatment in a hospital serving more Hispanic patients was associated with a 9% higher risk of mortality (odds ratio, 1.09; 95% CI, 1.07 to 1.11; P<0.01). The increased risk of mortality at these hospitals was found for white, black, and Hispanic patients. Median hospital length of stay was about one day longer at each of the disproportionately minority hospitals (5.9 days at hospitals serving more nonminority patients vs. 6.9 days at those serving more Hispanic patients and 6.7 days at those serving more black patients; P<0.01 for both comparisons).

Among other limitations, the NIS does not provide granular information to calculate well-validated sepsis severity-of-illness scores (e.g., Sequential Organ Failure Assessment score), the study authors noted. In addition, since the NIS does not allow for identification of individual hospitals on a state-level basis, relative disproportionate minority population was calculated based on hospital location within one of the nine Census Divisions throughout the country, they noted.

“Although our preliminary findings are interesting, the authors would like to stress that these should be characterized as hypothesis-generating findings and not definitive conclusions about the relationships between treatment in a disproportionately minority hospital and outcomes,” they concluded.