Medicolegal Issues

In the Literature


 

LITERATURE AT A GLANCE

Use this guide to find the abstracts below that correspond to these recent clinical findings

Would 24-hour Hospital Clinic Reduce LOS, Stroke Risk?

Background: Transient ischemic attacks (TIA) precede up to 25% of completed strokes and can provide opportunity for critical intervention if identified early. A specialty clinic with immediate access to imaging facilities could provide early identification and intervention.

Study design: Cohort study statistical analysis of data.

Setting: SOS-TIA hospital clinic in Paris.

Synopsis: A leaflet about TIA with a toll-free telephone number for SOS-TIA was sent to 15,000 family doctors, cardiologists, neurologists, and ophthalmologists in Paris. Between January 2003 and December 2005, 1,085 patients with suspected TIA were admitted to the clinic. The median duration of symptoms was 15 minutes. All patients were started on a stroke-prevention program, 5% had urgent carotid revascularization, and 5% were treated for atrial fibrillation with anticoagulants. Further, 74% of all patients seen were sent home the same day. The 90-day stroke rate was 1.24%; the rate predicted was 5.96%. Limitations of the study included selective patient recruitment from family doctors and office-based specialists. Also, the study lacked a randomized control group.

Bottom line: Prompt evaluation and treatment of patients in a dedicated TIA clinic is associated with a lower stroke risk. The TIA clinic also may lower costs via decreased length of hospital stay.

Citation: Lavallee P, Meseguer E, Abboud H, et al. A transient ischemic attack clinic with round the clock access (SOS-TIA): feasibility and effects. Lancet Neurol. 2007;6(11):953-960.

CLINICAL SHORTS

West of Scotland Coronary Prevention Study Shows Benefit 10 Years Out

This was a post-trial data comparison of clinical outcomes comparing Pravastatin with placebo in men showing the combined outcome of death from coronary heart disease or myocardial infarction was reduced from 7.9% to 5.5% 10 years after trial completion.

Citation: Ford I, Murray H, Packard CJ, Shepherd J, Macfarlane PW, Cobbe SM. Long-term follow-up of the west of Scotland Coronary Prevention Study. N Engl J Med. 2007;357:1477-1486.

Quality of Care Lower for Medicaid Population

Synopsis: A study of 383 managed-care health plans compared the quality of care provided to Medicaid enrollees using eleven quality indicators (HEDIS). The study concluded that Medicaid managed care enrollees received lower quality care than they received by commercial managed care enrollees.

Citation: Landon BE, Schneider EC, Normand S-LT, Scholle SH, Pawlson LG, Epstein AM. Quality of care in Medicaid managed care and commercial health plans. JAMA. 2007;298:1674-1681.

Discharge Communication with Elderly Patients Insufficient

This cross-sectional telephone survey of 269 patients age 70 years or older demonstrated significant gaps in communication between patients and hospital staff at the discharge interface. Patients receiving both verbal and written instructions were more likely to understand the discharges instructions.

Citation: Flacker J, Park W, Sims A. Hospital discharge information and older patients: do they get what they need? J. Hosp Med. 2007;2:291-296.

Social Issues Implicated in Hospital Readmission

This semistructured, open-ended interview conducted with 21 patients demonstrated that difficult life and social circumstances outside the hospital can be as significant to clinical recovery and hospital readmission as the discharge system and coordination of care.

Citation: Strunin L, Stone M, Jack B. Understanding rehospitalization risk: can hospital discharge be modified to reduce recurrent hospitalization? J Hosp Med. 2007;2:297-304.

Recognize Barriers to Patient Mobility in the Hospital

The study design consisted of qualitative interviews with 29 participants (including patients, nurses, and resident physicians). The findings indicated that there were multiple barriers affecting patient mobility including patient, treatment, institutional, and attitudinal factors. There was a divergence between patient and healthcare providers regarding the cause of attitudinal barriers.

Citation: Brown CJ, Williams BR, Woodby LL, Davis LL, Allman RM. Barriers to mobility during hospitalization from the perspectives of older patients and their nurses and physicians. J Hosp Med. 2007;2:305-313.

Prior Pneumococcal Vaccination Improves Outcomes in Patients with CAP

This was a prospective study that involved 3,415 adults admitted with community-acquired pneumonia to six hospitals between 2000 and 2002. It demonstrated that previous inoculation with pneumococcal vaccine leads to better outcomes in those patients who go on to develop pneumonia and require hospitalization. These patients had a 40% relative reduction in hospital mortality or need for ICU admission.

Citation: Johnstone J, Marrie TJ, Eurich DT, Majumdar SR. Effect of pneumococcal vaccination in hospitalized adults with community-acquired pneumonia. Arch Intern Med. 2007;167:1938-1943.

Serum Calcium Level Predicts Stroke Volume

This was an analysis of data involving 173 patients with acute ischemic stroke whose total serum calcium levels were measured on admission. Higher serum calcium levels were associated with smaller cerebral infarct volumes.

Citation: Buck B, Liebeskind DS, Saver JL, et al. Association of higher serum calcium levels with smaller infarct volumes in acute ischemic stroke. Arch of Neurology 2007;64:1287-1291.

Can Early Treatment after TIA or Minor Stroke Reduce Risk of Early Recurrent Stroke?

Background: In the week following a TIA or a minor stroke, the risk of recurrent stroke grows to 10%. These warning events provide a limited window of opportunity for prevention. Several treatments are effective in stroke prevention following TIA or minor ischemic stroke if identified early. These include aspirin, other antiplatelet agents, blood-pressure (BP) medications, statins, anticoagulation for atrial fibrillation, and endarterectomy.

Study design: Prospective before-versus-after study (Oxford Vascular Study, or OXVASC) within population-based incidence study.

Setting:: The study population was located in primary care practices in the United Kingdom.

Synopsis: The OXVASC study looked at 1,278 patients who presented with TIA or stroke: 607 were referred directly to the hospital, 620 were referred for outpatient assessment, and 51 were not referred to secondary care. In phase 1, a daily TIA and minor stroke clinic was introduced. Collaborating primary care physicians were asked to refer all patients suspected of having TIA and minor stroke. Phase 1 took place between April 1, 2002, and Sept. 30, 2004. The treatment protocol recommended aspirin in patients not already on anti-platelet therapy (75 mg daily) or clopidogrel if aspirin was contraindicated; simvastatin (40 mg daily); BP lowering agents unless systolic BP less than 130 mm Hg; and anticoagulation as required.

In phase 2, from Oct. 1, 2004, to March 31, 2007, a clinic was established at which no appointments were necessary, treatment was initiated immediately, and diagnosis was confirmed. Patients were assessed in the same way as in phase 1, but all those considered to have had a TIA or stroke were given aspirin 300 mg together with a prescription of any other study medication to start the same day. A loading dose of clopidogrel 300 mg was also prescribed. The 90-day risk if recurrent stroke in the patients referred to the study clinic was 10.3% in phase 1 and 2.1% in phase 2.

Bottom line: Early treatment after TIA or minor stroke was associated with an 80% reduction in the risk of recurrent stroke.

Citation: Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischemic attack (TIA) and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007;370:1432-1442.

How Does Prasugrel Compare With Clopidogrel in Acute Coronary Syndrome?

Background: Short-term and long-term benefits of a dual anti-platelet therapy for patients with acute coronary syndromes and/or PTCA has been well established but limited by recurrent atherothrombatic events and safety issues.

Study design: Double-blind, randomized study.

Setting: Triton-TIMI 38 Study Group.

Synopsis: This study randomly assigned 13,608 patients with acute coronary syndromes from 30 countries to a treatment group between November 2004 and January 2007. The study protocol used a loading dose of prasugrel (60 mg) within 72 hours before randomization and one hour after cardiac catheterization.

After percutaneous coronary intervention (PCI) patients received maintenance doses of either prasugrel (10 mg) or clopidogrel (75 mg) daily. Daily aspirin (75-162 mg) was required. The outcome of this study showed a significant reduction in the rate of ischemic end points (nonfatal myocardial infarction, stroke, and death) and stent re-thrombosis with prasugrel over clopidogrel. This was theorized to be due to the more rapid onset of antiplatelet effect with prasugrel and improved inhibition of platelet aggregation. Bleeding episodes were more frequent in the prasugrel group. Limitations of the study included the choice of vessels treated, devices used, and adjunctive medication administered to support PCI. All were left to the discretion of the treating physician.

Bottom line: Prasugrel therapy was significantly better than clopidogrel but with an increased risk of major bleeding.

Citation: Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357:2001-2015.

Can the Rate of New Hip Fracture Be Reduced with Zoledronic Acid?

Background: Mortality is markedly increased following hip fractures, and medical interventions exist to improve clinical outcomes.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: International, multicenter trial involving patients with recent hip fracture.

Synopsis: This study, know as the HORIZON trial, involved 2,127 patients. Of those, 1,065 (mean age of 74.5) were assigned to receive yearly infusions of 5 mg IV zoledronic acid within 90 days after surgical hip fracture repair. Meantime, 1,062 were assigned to receive placebo.

All patients received supplemental vitamin D and calcium. The median follow-up was 1.9 years, and the primary end point was a new clinical fracture. The rate of any new clinical fracture was 8.6% in the zoledronic acid group and 13.9% in the placebo group. This represents a 35% relative risk reduction with zoledronic acid.

Limitations of the study included a slightly younger and healthier patient population with hip fracture than the general population.

Bottom line: An annual infusion of zoledronic acid within 90 days after repair of hip fracture was associated with reduced new fractures and improved survival.

Citation: Lyles KW, Colon-Emeric CS, Magaziner JS, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357:1799-1809.

Does Peri-operative Consultation Improve Post-operative Outcome, Reduce Hospital Cost?

Background: Hospitalist-surgical co-management of the surgical inpatient is a model of care enjoying increasing interest. However, there is little published evidence of the effectiveness of this model.

Study design: Retrospective chart review.

Setting: Surgical service of academic teaching hospital.

Synopsis: Of 1,282 surgical patients, 9.1% underwent perioperative medical consultation in a retrospective review. Based on a number of measurement variables (post-operative serum glucose, venous thromboembolism [VTE] prophylaxis, use of perioperative beta-blockers), consulted patients had the same outcome, length of stay and cost as did non-consulted patients. This was, however, a retrospective observational study, using chart abstraction and administrative techniques. This introduces considerable weakness to the validity of the findings.

Bottom line:: In a retrospective study, no value was found to the use of peri-operative medical consultation of surgical patients in a large academic teaching hospital. Because of the weakness in study design, no conclusion can be drawn regarding the true effectiveness of perioperative medical consultation of the surgical patient.

Citation: Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli J. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007 Nov 26;167(21):2338-2344.

Does an RRT Save Children Outside the ICU?

Background: The Institute for Healthcare Improvement initiative known as the 100,000 lives campaign recommended six strategies to decrease preventable inpatient deaths. Implementation of a rapid response team (RRT) was one such strategy.

Study design: Cohort study design.

Setting: A 264-bed academic children’s hospital, between Jan. 1, 2001, and March 31, 2007.

Synopsis:

A total of 22,037 patient admissions and 102,537 patient days were evaluated pre-intervention, and 7,257 admissions and 34,420 patient days were evaluated post-intervention. Once the RRT was implemented, the mean morality rate decreased by 18% and the mean monthly code rate per 1,000 patient days were decreased by 71.2%. Study limitations included small differences in gender and race between pre-intervention and post-intervention populations.

This study is the first published study of pediatric inpatients to show significant reductions in both hospital wide mortality rate and code rate outside the intensive-care unit (ICU) setting after implementation of an RRT.

Bottom line: In an era of widely publicized hospital-related patient deaths the use of a pediatric RRT appears associated with reductions in inpatient codes and mortality.

Citation: Sharek PJ, Parast LM, Leong K, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children’s hospital. JAMA. 2007;298(19):2267-2274.

Does Influenza Vaccine Reduce Hospitalization, Death among Community Elderly?

Background: Most studies assessing the overall effectiveness of the influenza vaccine cover only a few influenza seasons. The need for long-term assessment was determined. Data were extracted retrospectively from HMO databases.

Study design: Retrospective (regression) analysis of pooled data.

Setting: One U.S. health maintenance organization. Data were pooled from 18 cohorts of community-dwelling elderly members of the HMO from 1990-2000.Synopsis: This study reviewed the effectiveness of influenza vaccine among patients 65 and older in community dwelling HMO members.

The study analyzed 713,872 person seasons over a 10-year period. The regression analysis revealed that influenza vaccination was associated with a 27% reduction in hospitalization for pneumonia/influenza and a 48% reduction in risk of death. The study was limited by inclusion of HMO enrollees only and may not have evaluated the vaccine effectiveness among the frailest elderly (e.g., nursing home dwellers). The study may have also been limited by misclassification of vaccination status.

Bottom line: Hospitalizations and deaths are prevented by influenza vaccination.

Citation: Nichol KL, Nordin JD, Nelson DB, Mullooly JP, Hak E. Effectiveness of influenza vaccine in the community dwelling elderly. N Engl J Med. 2007, 357; 1373-1381.

Is There a Simple, Effective Strategy to Reduce Primary Blood Stream Infections?

Background: An estimated 80,000 patients in U.S. ICUs incur catheter-associated bloodstream infections (BSIs). Reduction in BSI risk is the focus of several recent patient safety initiatives.

Study design: Two-arm, crossover clinical trial.

Setting: 22-bed medical ICU in Chicago.

Synopsis: This study took place over 52 weeks and involved 836 MICU patients. The patients were located in two ICUs at Cook County Hospital. One hospital unit was selected to serve as the intervention unit during which patients were bathed daily with 2% chlorhexidine gluconate (CHG)-impregnated washcloths. Patients in the concurrent control unit were bathed daily with soap and water. Outcome measures included incidences of primary BSIs and clinical sepsis (primary outcomes) and incidences of other infections (secondary outcomes). There were 4.1 vs. 10.4 primary infections per 1,000 patient days in the CHG intervention patients. Limitations in the CHG arm of the study were that patients had a slightly longer length of stay.

Bottom line: Daily cleansing of MICU patients with CHG-impregnated cloths is a simple and effective strategy to reduce primary BSIs.

Citation: Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein RA. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med. 2007;167:2073-2079.

Is There a Better Way to Prevent Central Venous Catheter-related Infections?

Background: The Centers for Disease Control and Prevention (CDC) has identified catheter-associated adverse events, including bloodstream infections, as one of its seven safety challenges. The CDC has set a goal to reduce these events by 50% in five years. This is the first study comparing chlorhexidine-based solutions and alcohol-based povidone-iodine solutions for skin disinfection at central venous catheter-insertion sites.

Study design: Randomized comparison study.

Setting: Surgical ICU of University Hospital of Poitiers, France.

Synopsis: This study randomized 538 catheters inserted in the ICU to the two antiseptic groups. The trial was conducted from May 14, 2004, through June 29, 2006. Before catheter insertion, the skin was disinfected twice with the assigned solution. Catheters were removed aseptically, and the distal 5 cm was placed in a sterile tube for subsequent culture in the microbiology lab.

The microbiologists were unaware of the type of antiseptic solution used. In all, 481 catheters produced culture results. The chlorhexidine-based solution was associated with a 50% decrease in catheter colonization. The study couldn’t be conducted in a blinded manner because the two solutions are different colors.

Bottom line: Chlorhexidine-based solutions should be used as a replacement for povidone-iodine formulations to prevent central venous catheter-related infections.

Citation: Mimoz O, Villeminey S, Ragot S, et al. Chlorhexidine-based antiseptic solution vs. alcohol-based povidone-iodine for central venous catheter care. Arch Intern Med. 2007;167:2066-2072. TH

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