Home News Briefs Guidelines widen tPA window, with caveats

Guidelines widen tPA window, with caveats

July 2009

Published in the July 2009 issue of Today’s Hospitalist

New guidelines on tPA

A NEW SCIENTIFIC ADVISORY recommends expanding the timeframe for delivering IV tissue plasminogen activator (tPA) to patients post-stroke, but advises against an expanded tPA-administration window for some patients.

The advisory from the American Heart Association/American Stroke Association recommends that tPA be administered to patients up to 4.5 hours post-stroke, a change from the previous three-hour treatment window. The new recommendation comes in the wake of a European study published in the Sept. 25, 2008, New England Journal of Medicine that tested the longer timeframe.

The new advisory, which was published in the May 2009 issue of Stroke, did list several types of patients who should not be included in that expanded window. Those include:

  • patients over age 80;
  • patients taking oral anticoagulants who have an INR of < 1.7;
  • individuals with a baseline National Institute of Health Stroke Scale of > 25; or
  • patients with a history of stroke or diabetes.

Costlier end-of-life care doesn’t mean better quality

ONE OF THE FIRST NATIONWIDE ANALYSES of the association between quality and spending at individual hospitals has found that higher spending in the last two years of life “typically due to more ICU care, as well as more tests and specialty care “is associated with significantly poorer quality of care.

Researchers from Dartmouth and Harvard pointed out that a negative association between hospital spending and quality has been found on a regional level. But they wanted to drill down to individual hospitals and more narrow geographic areas. They compared hospital spending at more than 2,100 hospitals with 10 HospitalCompare-reported process-of-care quality measures on acute MI, pneumonia and heart failure for Medicare patients in the last two years of their life.

Rather than finding any positive correlation between spending and quality, the study found a significant negative association, particularly in acute MI and pneumonia. Researchers found similar results when looking at only academic medical centers, and they found no correlation between spending and quality within specific cities.

The study, which was published on the Health Affairs Web site in May, recommended that in addition to posting their performance on quality measures, hospitals should post spending figures as well.

Downturn hitting budgets for infection prevention

A SURVEY OF INPATIENT INFECTIOUS DISEASE PROVIDERS found that many are struggling with reduced budgets, staff cuts and hiring freezes.

The survey, released last month, was conducted in March 2009 by the Association for Professionals in Infection Control and Epidemiology (APIC). Nearly 2,000 infection disease providers responded, three-quarters of whom work at acute care hospitals.

According to survey results, 41% of respondents said their budget for infection-prevention efforts had been cut within the last 18 months, mainly due to the economic downturn. Three-fourths of those whose budgets had been cut said they had to reduce efforts to train health care personnel in infection prevention. Nearly 40% of those with reduced budgets had experienced layoffs or had less time for infection prevention, and 30% had hiring freezes in place.

The survey also found that only one in five respondents had data-mining programs in place to electronically monitor hospital data for signs of infection. Nearly two-thirds of respondents had only one or fewer full-time staff members dedicated to infection prevention.

More information is online at www.apic.org.

Patients bring outsized expectations to resuscitation

A RECENT STUDY has found that many inpatients have exaggerated expectations for the success of resuscitation efforts and that they could benefit from more in-depth code-status discussions.

Researchers interviewed 135 patients admitted to an academic medical center to learn their code-status preferences and their knowledge of resuscitation techniques and outcomes. Researchers found that only 27% of patients understood that CPR entails the use of a defibrillator.

More importantly, 60% of patients estimated their rate of survival to discharge post-CPR to be 60.4%, when the average rate is actually 18%. When patients learned that their odds of surviving CPR with good brain function was only 7%, one in five said that would influence their preference for being resuscitated. Only 30% had discussed resuscitation previously with a physician.

The study, which appeared in the June issue of Journal of Medical Ethics, concluded that physicians need to more thoroughly discuss code status and resuscitation to better match patient preferences to treatment orders.

PPIs up the risk of hospital-acquired pneumonia

RESEARCHERS HAVE FOUND that non-ventilated patients prescribed proton pump inhibitors (PPIs) run a 30% greater risk of developing pneumonia while in the hospital.

The study, published in the May 27 Journal of the American Medical Association, adds to previous trial results that have seen an association between the use of PPIs and the incidence of C. difficile, ventilator-associated pneumonia and community-acquired pneumonia. The authors noted that between 40% and 70% of all inpatients receive some form of acid-suppressive drugs in the hospital, and that half of those patients are discharged with a prescription for those medications.

Researchers studied all non-ICU admissions in a Boston academic medical center from 2004 through 2007. While they also studied the use of histamine2 receptor antagonists, they found significantly increased risk only in patients prescribed PPIs.

Hospital-acquired pneumonia occurred in 3.5% of those admissions, which broke down into 4.9% of those receiving acid suppression vs. 2.0% of patients who did not.