Medicolegal Issues

The latest research you need to know


Literature at a Glance

Does management of ICU patients by critical care physicians reduce mortality?

Background: There is variation in the extent of involvement by critical care physicians in managing patients in ICUs. Several small studies have demonstrated improved outcomes when patients are managed by critical care physicians. This study expanded these findings by examining a national database of multiple ICUs.

Study design: Retrospective database analysis.

Setting: 123 ICUs in 100 U.S. hospitals

Synopsis: Using a national database of ICU patients, 101,832 admissions were analyzed. Controlling for ICU characteristics, patient demographics, and severity of illness (SOI), the impact of critical care management (CCM) on the primary outcome of hospital mortality was analyzed. Patients who received CCM had higher SOI, received more procedures, and had higher mortality rates than those who did not receive CCM. After adjustment for these variables, hospital mortality rates were higher for those patients who received CCM.


By Bradley Sharpe, MD, Rachael Lucatorto, MD, Lindsay Mazotti, MD, Nima Afshar, MD, Diane Sliwka, MD, University of California, San Francisco Division of Hospital Medicine


Randomized trial comparing everolimus- to paclitaxel-eluting stents in coronary artery disease showed decreased restenosis (nine month angiography) and fewer major adverse cardiac events at one year in the everolimus group.

Citation: Stone GW, Midei M, Newman W, et al. Comparison of an everolimus-eluting stent and a paclitaxel-eluting stent in patients with coronary artery disease: a randomized trial. JAMA. 2008;299(16):1903-1913.


In a population-based surveillance study, the incidence of invasive group B streptococcal disease in the United States decreased in newborns but increased and remains substantial in adults.

Citation: Phares CR, Lynfield R, Farley MM, et al. Epidemiology of invasive group B streptococcal disease in the United States, 1999-2005. JAMA. 2008;299(17):2056-2065.

Beta-lactams Equivalent to Non-beta-lactams for Cellulitis

Retrospective observational study of 861 veterans with uncomplicated cellulitis showed oral beta-lactams had a failure rate (14.7%) equal to that of oral non-beta-lactams (17%) with fewer adverse effects.

Citation: Madaras-Kelly KJ, Remington RE, Oliphant CM, et al. Efficacy of oral beta-lactam versus non-beta-lactam treatment of uncomplicated cellulitis. Am J Med. 2008;121:419-425.


A single-center, retrospective study showed transfusion of red blood cells that had been stored more than 14 days was associated with worse outcomes, including sepsis, longer intubation, renal failure, and short- and long-term mortality, after cardiac surgery.

Citation: Koch C, Li L, Sessler D, et al. Duration of red-cell storage and complications after cardiac surgery. N Engl J Med. 2008;358:1229-1239.


In a case-control study of women in a clinical practice setting, every use of alendronate was associated with a higher risk of incident atrial fibrillation (OR 1.86).

Citation: Heckbert SR, Li G, Cummings SR, Smith NI, Psaty BM. Use of alendronate and risk of incident atrial fibrillation in women. Arch Intern Med. 2008;168(8):826-831.


A telephone survey of Medicare beneficiaries revealed limited knowledge of Part D cost sharing and evidence of frequent behavioral change to pay for gaps in coverage.

Citation: Hsu J, Fung V, Price M, et al. Medicare beneficiaries’ knowledge of Part D prescription drug program benefits and responses to drug costs. JAMA. 2008;299(16);1929-1936.


This observational study demonstrated decreases in cost-related medication non-adherence and reduced prevalence of foregoing food and basic needs to pay for medications one year after the implementation of Medicare Part D.

Citation: Madden JM, Graves AJ, Zhang F, et al. Cost-related medication non-adherence and spending on basic needs following implementation of Medicare Part D. JAMA. 2008;299(16):1922-1928.


Meta-analysis of randomized controlled trials found that, compared with placebo, long-acting beta-agonists reduce severe exacerbations and improve airflow, quality of life, and rescue medication use in COPD.

Citation: Gustavo JR, Nannini LJ, Rodriguez-Roisin R. Safety of long-acting beta-agonists in stable COPD. Chest. 2008;133:1079-1087.

Because this was a retrospective analysis, it is not possible to state there was a causal relationship between care by a critical care physician and worse outcome. Other unmeasured clinical differences between the patients receiving CCM and those that did not may have existed that resulted in the higher mortality. Additionally, although the database identified management by a critical care physician, it did not differentiate whether the management was by a full-time intensivist. Therefore, conclusions cannot be made regarding the value of full-time, on-site intensivist management.

Bottom line: Additional analysis is required to determine the value of intensivists in the management of critically ill patients.

Citation: Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Association between critical care physician management and patient mortality in the intensive care unit. Ann Int Med 2008; 148: 801-809.

What is the frequency of iatrogenic drug overdose in patients with renal insufficiency?

Background: The Institute of Medicine Report, “To Err is Human” suggested 7,000 deaths occur annually because of medication errors. Renal insufficiency is relatively common in hospitalized patients. Previous studies have suggested overdose of medications is frequent in patients with renal insufficiency. There is a lack of large-scale studies identifying the most commonly overdosed medications and the predictive physician factors for these errors.

Study design: Retrospective observational study.

Setting: A single 1,080-bed tertiary teaching hospital

Synopsis: A clinical data mart was constructed that contained 48 months of prescription data, serum creatinine levels, along with physician characteristics. 28,954 patients with renal insufficiency had 431,119 prescription orders to analyze. 3.5% of drug doses were found excessive. The overdose rate in patients with moderate to severe renal insufficiency was 28.2%. 10 drugs accounted for 85.4% of the overdoses. There was a negative correlation between physician clinical experience and overdose rate.

Study results are limited by the study’s retrospective nature. Further, the prescribed dose was presumed to be the dose actually administered, and there were no data on the actual doses given to patients. The study was limited to a single institution and may not be generalizable.

Bottom line: Iatrogenic drug overdose is quite common among inpatients with renal insufficiency. Only a few drugs are commonly responsible. The physicians’ clinical experience, workload of prescriptions, and patients’ renal function correlated with overdose.

Citation: Sheen SS, Choi JE, Park RW, Kim EY, Lee YH, Kang UG. Overdoser rate of drugs requiring renal dose adjustment: data analysis of 4 years prescriptions at a tertiary teaching hospital. J Gen Intern Med 2007;23(4):423-8

Will a national education program based on the “Surviving Sepsis Campaign” guidelines improve survival and processes of care?

Background: Sepsis is one of the most prevalent diseases and one of the main causes of death among hospitalized patients. Several single-center studies have suggested quality improvement efforts based on the Surviving Sepsis Guidelines were associated with better outcomes.

Study design: Prospective multicenter before-and-after study design.

Setting: 59 medical and surgical ICUs throughout Spain.

Synopsis: 854 patients with severe sepsis were enrolled in the pre–intervention group. The intervention consisted of education on the use of bundles of care. The treatment was organized into two bundles: a resuscitation bundle (six tasks to be performed within six hours) and a management bundle (four tasks to be completed within 24 hours). 1,465 patients were enrolled in the post-training period. Hospital mortality, adherence to the bundles, ICU mortality, 28-day mortality, hospital and ICU length of stay were measured.

Patients in the post-intervention group had lower mortality (44.0% vs. 39.5% P=0.04) and better compliance with the bundles improved. No other outcomes improved. One year later, mortality gains persisted but compliance with the resuscitation bundle had lapsed.

This study did not employ a control group, making it difficult to ascribe the improvement in compliance solely to the training given (some improvement in processes may have occurred independent of the training).

Bottom line: A national education effort to promote bundles of care for severe sepsis and septic shock was associated with improved guideline compliance and lower hospital mortality.

Citation: Ferrer R, Artigas A, Levy MM, et al. Improvement in process of care and outcomes after a multicenter severe sepsis educational program in Spain. JAMA 2008;299(19):2294-2303.

Can SSRI and problem-solving therapy reduce the incidence of depression in non-depressed patients with a recent stroke?

Background: Depression occurs in more than half of previously non-depressed patients after a stroke. Post-stroke depression is associated with impaired recovery and increased mortality.

Study design: A multicenter randomized controlled trial.

Setting: Two urban university-affiliated hospitals and a suburban rehabilitation hospital in the U.S.

Synopsis: 178 patients age 50 to 90 were enrolled within three months of an index stroke in a 12-month trial. The patients were randomized into three groups of a double-blind placebo control comparison of escitalopram with placebo, and non-blinded problem-solving therapy group.

During the period of the trial, patients on escitalopram experienced significant reductions in the incidence of depression versus placebo (23.1% vs. 34.5%). Problem-solving therapy did not result in significant benefit over the placebo.

The study results were limited by several factors. The study did not include all patients with acute stroke, employed a relatively small sample size, used a non-blinded psychological problem-solving therapy group, and had a high drop out rate.

Bottom line: Consider SSRI use to prevent depression in post-stroke patients.

Citation: Robinson RG, Jorge RE, Moser DJ, et. al. Escitalopram and problem-solving therapy for prevention of post stroke depression: a randomized controlled trial. JAMA 2008;299 (20):2391-2400


By Kenneth Epstein, MD, Brian Donovan, MD, Augustine Osagie, MD, Richard Otto, MD, Marium Steele, MD


A double-blind randomized trial of patients with opioid-induced constipation demonstrated that methylnaltrexone was more successful than placebo in inducing defecation within four hours, without affecting analgesia or causing opioid withdrawal.

Citation: Thomas J, Karver S, Cooney GA, Chamberlain BH, Watt CK, et al. Methylnaltrexone for opioid-induced constipation in advanced illness. N Engl J Med. 2008;358:2332-43.


Multicenter, randomized, placebo controlled, parallel-group phase 3 trial of prucalopride in patients with severe constipation demonstrated significant improvement in bowel function versus placebo.

Citation: Camilleri M, Kerstens R, Rykx A, Vandeplassche L. A placebo controlled trial of prucalopride for severe chronic constipation. N Engl J Med. 2008;358:2344-2354


A systematic review of the literature on the use of surveillance cultures and control of MRSA infection found no high quality articles to support this strategy.

Citation: McGingle KL, Gourley ML, Buchanan IB. The use of active surveillance cultures in adult intensive care units to reduce methicillin-resistant Staphylococcus aureus-related morbidity, mortality, and costs: A systematic review. Clin Infect Dis 2008;46:1717-25.


A 10-year observational study demonstrated that only 11.5% of patients admitted to a nursing home after suffering hip, wrist or humeral fracture received osteoporosis medications.

Citation: Parikh S, Mogun H, Avorn J, Solomon DH. Osteoporosis medication use in nursing home patients with fractures in 1 US state. Arch Intern Med. 2008;168(10):1111-1115


A cross-sectional survey of diabetics showed that low diabetic numeracy skills were associated with possibly poorer glycemic control, including hemoglobin A1c levels of 7.65% versus 7.1%.

Citation: Cavanaugh K, Hulzinga MM, Wallston KA, Association of numeracy and diabetes control. Ann Intern Med. 2008;148(10):737-746.


A survey of patients with a history of acute myocardial infarction or invasive cardiac procedures for ischemic heart disease showed their knowledge of acute coronary syndrome symptoms and treatment options remained poor.

Citation: Dracup K, McKinley S, Doering LV, Acute coronary syndrome: What do patients know? Arch Intern Med. 2008;168(10):1049-1054.


A retrospective cohort study found low ABIM test scores and poor professionalism ratings during internal medicine residency correlated on a continuum basis with future state licensing board actions.

Citation: Papadakis MA, Arnold GK, Blank LL. Holmboe ES, Lipner RS. Performance during internal medicine residency training and subsequent disciplinary action by state licensing boards. Ann Intern Med. 2008;148:869-876.


Prospective cohort study compared the measurement of NGAL with other proteins and serum creatinine and found the measurement of NGAL better predicts renal injury and poor patient outcomes.

Citation: Nickolas TL, O’Rourke MJ, Yang J, et al. Sensitivity and specificity of a single emergency department measurement of urinary neutrophil gelatinase-associated lipocalin for diagnosing acute kidney injury. Ann Intern Med. 2008;148:810-819


A survey revealed most patients did not worry about the fatigue of their doctors or the discontinuity of medical care as implied by ACGME requirement of resident work hours.

Citation: Fletcher K, Wiest F, Halasyamani L, et al. How do hospitalized patients feel about resident work hours fatigue, and discontinuity of care? J Gen Intern Med. 2008;23(5):623-8.


Evaluating the quality of CPR by feedback defibrillators and performance debriefing improved the return of spontaneous circulation but did not result in a significant difference of survival at discharge.

Citation: Edelson D, Litzinger B, Arora V, et al. Improving in-hospital cardiac arrest process and outcome with performance debriefing. Arch Intern Med. 2008;168(10):1063-1069.

Do stop orders for indwelling urinary catheters reduce the duration of inappropriate urinary catheterization and incidence of urinary tract infection?

Background: About 25% of hospitalized patients have an indwelling urinary catheter inserted, and in 30% to 50% of these patients, urinary catheters are not indicated. Approximately 50% of patients with a catheter inserted for five days or more will develop bacteriuria with about 80% of hospital-acquired urinary tract infections occurring in patients with a urinary catheter.

Study design: A randomized controlled study.

Setting: Three tertiary care hospitals in Ontario, Canada.

Synopsis: 692 patients with indwelling urinary catheters admitted to seven general medical units in three tertiary care hospitals from January 2004 to June 2006 were randomized into two groups: 269 in the stop-order group, and 252 in the usual care group. Patients in the stop-order group had fewer days of inappropriate and total urinary catheter used (2.20 days) compared with the usual care group (3.89 days). There was no difference in the incidence of urinary tract infection between both groups.

Study results were limited by several factors, including a lack of control for exposure of participants to antimicrobials, missing urine cultures, and lack of evaluation of the effect of reducing urinary catheter use on mobility and quality of life. The 1.34-day reduction in the duration of catheterization may not be sufficient to significantly reduce bacteriuria.

Bottom line: Consider using stop orders in all patients with indwelling urinary catheters.

Citation: Loeb M, Hunt D, O’Halloran K, et. al. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized control trial. J Gen Intern Med 2008;23(6):816-820.

Does interrupting anticoagulation in patients with atrial fibrillation undergoing surgery cause an increased rate of thromboembolism?

Background: There is a known risk of thromboembolism (between 0.5% and 20% annually) in patients with atrial fibrillation. Studies are limited regarding the risk of thromboembolism with holding anticoagulation in the perioperative period for nonvalvular atrial fibrillation. This study attempted to answer this question.

Study design: Prospective cohort.

Setting: Thromboembolism clinic of the Mayo Clinic.

Synopsis: 345 patients with nonvalvular atrial fibrillation whose anticoagulation was perioperatively held were monitored for three months after surgery for thromboembolic events. Warfarin therapy was held for 5.3 days +/- three days before surgery and restarted 1.3 days +/- 3.4 days after surgery. Bridging heparin therapy was used for 204/386 procedures.

Four patients suffered six thromboembolic events; two patients while receiving bridging heparin therapy and two without heparin. The total incidence of thromboembolic events was 1.1%. This is compared with an expected incidence of 0.09% to 2.07% for patients with atrial fibrillation on warfarin. Bleeding complications rates were also low.

The authors recognized a possible selection bias and the fact patients who received bridging heparin therapy were not randomized. Despite these potential flaws, there seems to be minimal risk of holding anticoagulation in the perioperative period. Bridging heparin therapy added no additional benefit.

Bottom line: There is no increased risk of thromboembolism if anticoagulation is interrupted without bridging therapy in nonvalvular atrial fibrillation patients undergoing surgery.

Citation: Wysokinski WE, McBane RD, Daniels PR, et al. Periprocedural anticoagulation management of patients with nonvalvular atrial fibrillation. Mayo Clinic Proceedings 2008;83(6):639-645.

Are obese patients under-dosed when prescribed intravenous vancomycin?

Background: Weight-based vancomycin dosing has been recommended by the Infectious Diseases Society of America, yet flat dosing is still commonly employed. Flat dosing has the potential of increasing resistance and having adverse clinical effects.

Study design: Retrospective cohort.

Setting: Two tertiary care medical centers without pharmacy-guided vancomycin dosing programs.

Synopsis: A retrospective review was done of pharmacy prescription files at two tertiary care medical centers that did not have pharmacy-guided vancomycin programs. Patients were divided into cohorts based on their body mass index: underweight (<18.5 kg/sqm) normal weight (18.5-24.9 kg/sqm) overweight (25.0-29.9 kg/sqm) and obese (>29.9 kg/sqm). Each class was studied for rates of adequate vancomycin dosing which was defined as >10 mg/kg/dose. A total of 421 patients were included. There were no other dissimilar baseline characteristics. Total daily dose was similar for all groups with adequate initial dosing achieved in 100%, 99.0%, 93.9% and 27.7% for underweight, normal weight, overweight and obese patients, respectively.

Bottom line: Use weight-based dosing of vancomycin to limit the possibility of under-dosing in obese patients.

Citation: Hall RG, Payne KD, Bain AB, et al. Multicenter evaluation of vancomycin dosing: emphasis on obesity. Am J of Med. 2008;121:515-518.

What is the rate of adverse events with short-term antipsychotic therapy in elderly demented patients?

Study design: Population-based retrospective cohort study.

Setting: Community-dwelling cohort and nursing home cohort.

Synopsis: A cohort of patients from Ontario age 66 and older with the diagnosis of dementia and a prescription for an anti-psychotic drug between April 1, 1997, and March 31, 2004, were divided into two groups by where they lived (community or nursing home). Each cohort was further divided into three groups based on antipsychotic exposure of none, atypical, or conventional.

All serious adverse events (defined as extra-pyramidal symptoms (EPS), cerebrovascular events, and acute care hospital admission or death) were evaluated within 30 days of initiating therapy. In the community group, individuals who received conventional antipsychotic therapy were 3.8 times more likely to have an adverse event compared with the group taking no antipsychotics. The patients prescribed an atypical antipsychotic medicine were 3.2 times more likely to experience an adverse event. In the nursing home group, patients who received conventional and atypical antipsychotic therapy were 2.4 and 1.9 times more likely to have a serious adverse event, respectively.

Bottom line: Serious events are frequent following the short-term use of antipsychotic therapy in older adults with dementia. Serious adverse events were more common among those who received a prescription for conventional rather than atypical antipsychotic drugs.

Citation: Rochon PA, Normand SL, Gomes T, et al. Antipsychotic therapy and short-term serious events in older adults with dementia. Arch Intern Med. 2008;168(10):1090-1096

What is the association between troponin levels and adverse events in hospitalized patients with acute decompensated heart failure?

Background: There were more than 1 million hospitalizations for heart failure in 2007, making it the most costly medical condition based on diagnosis and treatment. Evidence suggests an initial risk stratification process allows for earlier implementation of aggressive therapy, which can affect hospital utilization.

Study design: Retrospective analysis of Acute Decompensated Heart Failure National Registry (ADHERE).

Setting: Hospitalization records from 274 hospitals from October 2001 to January 2004.

Synopsis: Evaluation of the data from ADHERE for outcomes associated with elevated troponin levels in patients with acute decompensated heart failure (ADHF). Patients who had a creatinine level above 2.0 mg per deciliter were excluded.

Cardiac troponin I was measured in 61,379 patients and cardiac troponin T in 7880 patients. Overall, 4,240 patients (6.2%) had an elevated troponin level. Troponin positive patients had a higher rate of in-hospital mortality than troponin negative patients (8.0% vs. 2.7%, P<0.001). The adjusted odds ratio for death among patients with a positive troponin test was 2.55. Ischemic heart failure was present in 53% of the troponin positive patients and was not a useful predictor of troponin status or mortality.

Bottom line: Measurement of troponin is an important prognostic indicator in the initial evaluation of patients with ADHF. This early assessment of risk should be factored into medical decisions with respect to triage and medical management.

Citation: Peacock FW, De Marco T, Fonarow GC, et al. Cardiac troponin and outcome in acute heart failure. N Engl J Med 2008;358:2117-26

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