Bottom Line: CDAD is associated with high 30-day mortality rate but no less attributable mortality. Preventing horizontal transmission in the hospital may reduce mortality.
Citation: Kenneally C, Rosini JM, Skrupky LP, et al. Analysis of 30-day mortality for C. difficile-associated disease in the ICU setting. Chest. 2007;132:418-424.
Background: Community-acquired pneumonia (CAP) results in significant costs to the healthcare system. Length of stay (LOS) affects cost as well as risk for hospital-acquired medical complications. CAP studies have found that guideline adherence improves outcomes such as mortality but does not reduce LOS.
Study design: Sequential course of study with three consecutive blocks of patients.
Setting: Single-institution teaching hospital.
Synopsis: Three consecutive blocks of approximately 110 patients were enrolled. Block 1 patients underwent treatment not guided by order sets or case management. For block 2 patients, clinicians were reminded to use the order sets. If the care processes were not completed, case managers (trained medical residents) would intervene. Emphasis was placed on prompting for timely conversion to oral antibiotics and discharge.
For block 3 patients, clinicians were reminded to use order sets, but no case management was involved. Among the groups, no difference in pneumonia severity or time to clinical stability was found. The mean LOS was 8.8 days in block 1, 5.3 days in block 2, and 7.3 days in block 3.
Order sets (block 3) reduced LOS by 1.5 days (p=0.01) over conventional therapy (block 1). Order sets combined with case management (block 2) reduced LOS by 3.5 days (p<0.001) over conventional therapy.
Bottom Line: Standardized order sets combined with intensive case management reduce LOS in CAP. However, the cost effectiveness and long-term application of this approach are uncertain.
Citation: Fishbane S, Niederman MS, Daly C, et al. The impact of standardized order sets and intensive clinical case management on outcomes in community-acquired pneumonia. Arch Intern Med. 2007;167:1664-1669.
Background: The American College of Radiology recommends daily chest radiographs (CXR) on patients in the intensive care unit (ICU), regardless of the patient’s clinical status. Previous non-blinded studies suggested CXR should be obtained in the ICU only when clinically indicated but did not address the utility of routine daily CXR in finding unsuspected pathology.
Study design: Prospective controlled study.
Setting: University-affiliated hospital ICU in the Netherlands.
Synopsis: For one year, 1,780 daily routine CXR on 559 ICU admissions were reviewed by a radiologist and blinded to the attending physician, who could view radiographs ordered with a clinical indication.
Daily CXR assisted in a diagnosis in 4.4% of cases, most frequently detecting infiltrates or tracheal tube malposition. These findings resulted in a change in clinical management in only 1.9% of the total. For the following six months, daily CXR was abandoned and data were collected on ICU length of stay, readmission, mortality, and cost. The study was not powered to detect differences between the two groups.
This is an observational study that does not provide outcome data on routine daily CXR in either specific disease states or on general ICU patients. Also, the mixed medical-surgical ICU setting may be difficult to generalize to some hospitalists’ practices.
Bottom Line: Routine daily CXR in the medical-surgical ICU has a low diagnostic and therapeutic value.