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CPR: Longer is better

Plus, not your parents' attendings

October 2012

Published in the October 2012 issue of Today’s Hospitalist

CPR: Longer may be better

AN OBSERVATIONAL STUDY looking at the amount of time spent doing cardiopulmonary resuscitation (CPR) for patients with in-hospital arrests suggests that prolonging CPR leads to better survival rates with similar neurological outcomes.

Authors writing in a study posted online by The Lancet analyzed data on 65,000 cardiac arrests in more than 400 U.S. hospitals between 2000 and 2008. They found wide variation in the amount of time spent on CPR, ranging from 16 to 25 minutes. Among patients studied, 48.5% had spontaneous circulation return and 15.4% survived to discharge.

Patients receiving the most prolonged resuscitation efforts had a 12% greater chance of surviving to discharge than those receiving the least. Current guidelines don’t spell out how long resuscitation efforts should last, and the Lancet authors weren’t able to recommend any “”optimum duration.” But researchers suggested that standardizing CPR times and increasing the duration of CPR could improve survival rates and patient outcomes.

Hyponatremia ups 30-day surgical mortality

EVEN MILD HYPONATREMIA increases patients’ 30-day mortality rates, according to a cohort study of registry data.

Research posted online in September by Archives of Internal Medicine looked at 2005-10 data for nearly 1 million patients whose sodium levels were measured within 90 days before surgery. Eight percent of those patients were found to have hyponatremia, defined as serum sodium levels below 135 mEq/L. Most of those cases, however, were mild.

Thirty-day mortality rates for those patients were higher, as were rates of major coronary events, wound infections and pneumonia. (The association between risk for higher 30-day mortality and hyponatremia was particularly evident for patients undergoing nonemergency surgery.) The authors also noted that patients with hyponatremia spent a median of one day longer in the hospital.

The author of an accompanying editorial pointed out that it was unclear if elective surgery should be postponed in patients found to have mild hyponatremia. But the editorialist wrote that the diagnosis should be considered part of informed consent.

How accurate is POA reporting?

A LOOK AT THE FINANCIAL IMPACT of the 2008 decision made by the Centers for Medicare and Medicaid Services (CMS) to not pay for complications of hospital-acquired conditions found that the penalty hasn’t made much of a dent in hospital payments.

That’s in large part because, researchers learned, claims data don’t accurately reflect the real number of those conditions that aren’t present on admission, at least in terms of one condition: catheter-associated UTIs. The study was published in the Sept. 4 issue of Annals of Internal Medicine.

Authors analyzed claims data for both 2007 and 2009 from 96 hospitals throughout Michigan. Epidemiologic data suggest that the vast majority of UTIs in the hospital are catheter-associated. However, researchers found that the 2009 claims data indicated a very low rate of those UTIs. As a result, hospitals were financially penalized for relatively few cases.

A corresponding editorial noted the high stakes of inaccurate claims data, given the expanding list of hospital-acquired conditions and complications that the CMS won’t pay for.

Patient satisfaction: It’s all about the people

HOSPITALS RUSHING TO BULK UP patient amenities and clinical technology to improve their patient satisfaction scores should invest instead in boosting the social and communication skills of clinicians and staff. That’s according to a patient experience report from the marketing firm J.D. Power.

The report indicated that admitted patients have a high level of satisfaction, giving hospitals 825 points out of a possible 1,000. That’s similar, the report said, to how highly consumers rate a stay in luxury hotels.

However, facilities accounted for only 19% of patients’ overall satisfaction ratings. But doctors and nurses made up 34% of inpatients’ overall ratings “and an even higher percentage of overall ratings from patients in the ED (43%) and in outpatient settings (50%).

Staff service and attitudes were particularly important to satisfaction levels. To improve patients’ overall satisfaction scores, the report also recommended that hospitals improve admission and discharge by getting patients into their rooms quickly and ensuring a smooth discharge process. Together, admission and discharge were associated with 35% of inpatients’ overall satisfaction scores.

Hospitals recruit, even with no openings

DO YOUHAVE A HOSPITAL IN MIND where you’d like to work, but it’s not advertising any open positions? National recruiters say that hospitals continue to recruit even when they have no immediate slots available, and that doctors should approach institutions where they’d like to work, regardless of whether positions are currently open or not.

According to American Medical News, a survey of 250 hiring managers done by CareerBuilder, a job Web site, found that 51% of those managers were recruiting for openings they expected in the future. In addition, 43% said they maintained a pipeline of potential candidates.

Doctors who post a resume on a job board might receive as many as 500 responses within 48 hours, the coverage stated, making it impossible for physicians to wade through all those options. But recruiters recommended a much more targeted strategy. Instead, they noted that physicians interested in particular institutions should contact the CEOs of those hospitals or the people in charge of physician relations.

Not your parents’ attendings

TODAY’S ATTENDINGS “who tend to be hospitalists “are much younger than their counterparts of a decade or so ago. They also have a profoundly different relationship with housestaff.

Those are two conclusions of a viewpoint published in the Sept. 12 issue of Journal of the American Medical Association (JAMA) penned by Robert Wachter, MD, who heads up the hospitalist service at the University of California, San Francisco, and Abraham Verghese, MD, a writer and Stanford University professor.

Factors behind the changing dynamics within teaching include duty-hour restrictions, computerization, and a growing emphasis on quality and safety. The authors wrote that attendings today are also much more involved in patient care and don’t give housestaff the kind of clinical autonomy they once had. In a JAMA podcast, the authors claimed that such autonomy may have been unethical.

Another key difference in academic medicine? Subspecialists used to serve much more frequently as attendings. The authors note that they’d like subspecialists to be re-integrated into teaching either via teaching conferences or by serving as co-attendings.