Published in the April 2016 issue of Today’s Hospitalist
New CDC guidelines target opioid prescribing
FOR THE FIRST TIME, the CDC last month released national guidelines on prescribing opioids for patients with chronic pain. The guidelines, which target primary care physicians, have been opposed by the pharmaceutical industry and pain doctors. The CDC is promoting them as an effort to curb opiate addiction and overdoses.
Among 12 recommendations, the guidelines say that doctors should first try pain relievers like ibuprofen and aspirin before prescribing opioids. When prescribing opioids, they should prescribe the lowest effective dose and immediate-release opioids, not extended-release or long-acting.
As for prescribing opioids for acute pain, the guidelines note that treatment lasting three days is usually sufficient and that patients will rarely need opioids prescribed for more than seven days. Other recommendations give guidance on when clinicians should evaluate patients after starting opioids or escalating their doses.
The guidelines were posted online last month by the Journal of the American Medical Association. They do not apply to surgical or cancer patients or patients at end of life.
New sepsis definitions toss out SIRS criteria
REVISED DEFINITIONS for sepsis and septic shock throw out SIRS criteria, which have long been notorious for low specificity.
Instead, sepsis is now defined as evidence of infection and life-threatening organ dysfunction characterized by a change of two points or more in the SOFA score, a scoring system used to determine organ function or extent of failure. The new definition of septic shock includes sepsis with fluid-unresponsive hypotension, a serum lactate level of more than 2 mmol/L, and the need for vasopressors to maintain a MAP of 65 mm Hg or more.
The revised definitions were released at a Society of Critical Care Medicine conference in late February and have been endorsed by several dozen other medical societies. They were also published in the Feb. 23 issue of the Journal of the American Medical Association.
The updated definitions, according to the task force that released them, should “facilitate earlier recognition and more timely management.” Sepsis and septic shock definitions were last issued in 2001.
Hospitalists sued for delayed or absent diagnoses
WHEN HOSPITALISTS are sued for malpractice, it’s most often because of a delayed or absent diagnosis. That’s according to a new report from The Doctors Company, a medical malpractice insurer, that was released at last month’s annual meeting of the Society of Hospital Medicine.
The report found that 36% of malpractice claims that closed between 2007 and 2014 against the 2,100 hospitalists the company covers were related to missed, late or incorrect diagnoses. Of those claims, 35% resulted from an inadequate initial assessment. Intestinal disorders like obstruction, perforation and vascular insufficiency led the list of incorrect or delayed diagnoses.
However, almost one-third of the remaining claims (31%) were due to improper management of treatment. Examples included inadequate assessments of pressure ulcers that resulted in sepsis.
In addition, 11% of claims resulted from medication errors, 5% cited improper performance or delay in treatment or procedure, and 3% each were the result of failure to treat or failure to monitor physiologic status.
More than 25% of all readmissions are preventable
NEW DATA indicate that more than one-quarter (27%) of hospital readmissions could be prevented through improved communication and better post-discharge resources.
A study led by several hospitalists and published online in March by JAMA Internal Medicine looked at readmissions in 2012-13 across 12 academic centers. Researchers found that 15% of those readmissions had “strong” or “virtually certain” evidence that they could have been prevented, while 12% had a 50-50 chance of being prevented.
As for why preventable readmissions had occurred, 9% were chalked up to EDs unnecessarily admitting patients in the first place, while 8% were linked to patients not being able to keep outpatient appointments after discharge. Another 8% were due to premature discharge of patients from the hospital.
Six percent were linked to patients’ lack of awareness of who they needed to contact after discharge. Still another group of potentially preventable readmissions was due to the lack of a documented goals-of-care discussion with patients who had end-stage disease.
Is ARDS under-recognized?
ACCORDING TO A NEW STUDY, ARDS is not only under-diagnosed, but it’s also significantly under-treated.
The study, which was published in the Feb. 23 Journal of the American Medical Association, evaluated four weeks of 2014 data from nearly 460 ICUs in 50 countries. Researchers found that ARDS was common, accounting for 10% of all ICU admissions, and that it had very high in-hospital mortality: 35% among patients with mild ARDS, 40% for moderate and 46% for patients with severe ARDS.
But clinicians identified only one-third (34%) of cases in which patients met ARDS criteria, and only 60% of cases were recognized at any point. Further, the research found that many ARDS patients didn’t receive proven interventions, including low tidal volume ventilation, higher PEEP and prone positioning.
An accompanying editorial concluded that the research “demonstrates that improved recognition of ARDS might be the best place to start.”
Wide variations in PICC indications, complications
WHILE THE USE of PICC lines has grown substantially in hospitals, an observational study of 10 medical centers in Michigan has found substantial variations in both indications for PICC lines and PICC-line complications.
While “difficult venous access” was the most common indication for placing a PICC line, that rationale was used to justify only 10% of the PICCs placed in some of the hospitals studied, but as many as 64% in others. Complication rates related to PICC lines ranged from 4% to 36%, with catheter thrombosis and VTE among the most common problems.
Study results were posted online in February by JAMA Internal Medicine. In the study, the majority of PICCs (71%) were placed by vascular access nurses. Across all sites, the median dwell-time for PICCs was 10 days, although 24% of PICCs were removed within five days.
ACA: Faster fall in readmission rates
NEW DATA SHOW that the Affordable Care Act (ACA) appears to have accelerated a reduction in hospital readmissions.
Researchers found that after the ACA was passed in April 2010, readmissions for conditions targeted by the law began to drop more quickly. Between 2007 and 2015, readmission rates for conditions including AMI, heart failure and pneumonia dropped from 21.5% to 17.8%.
The authors noted that readmissions for conditions not targeted by the ACA also fell, but not as fast. Results were published in the Feb. 24 issue of the New England Journal of Medicine.
The research also indicated that while the number of observation stays increased from 2.6% before ACA passage to 4.7% in 2015, there was no association between changes in the use of observation services and changes in readmission rates.
The authors compared monthly hospital-level rates of both readmissions and observation stays within 30 days of discharge for Medicare beneficiaries. “Our analysis,” they wrote, “does not support the hypothesis that increases in observation stays can account in any important way for the reduction in readmissions.”
Online tool reduces “defective” handoffs from ED
A RECENT STUDY found that an electronic tool was able to cut in half the number of problem handoffs from the ED.
Researchers examined 107 handoffs from the ED to four private physician groups at a 73-bed community hospital in Alaska. Before the tool was implemented, 29% of handoffs were judged to be defective because of factors that included inaccurate or incomplete information.
After the tool was implemented, the rate of defective handoffs fell to 12%. Researchers examined the Targeted Solutions Tool, a product from the Joint Commission that focuses on quality improvement areas like improving handoffs and reducing falls.
Results were published in the Joint Commission Journal on Quality and Patient Safety. In addition to incomplete or inaccurate information, other common causes of defective handoffs included a lack of standardized handoff procedures and a lack of knowledge about a patient by the person initiating the handoff.
Contract language that can affect patient care
WHILE YOU MAY THINK that your contract covers only compensation and the number of shifts you need to work per year, an opinion piece in Annals of Internal Medicine claims that many contracts for employed physicians contain clauses that can affect patient care.
The piece was published in the March 8 issue. The authors pointed to problem areas in contracts, including confidentiality clauses that may make it hard to reveal quality or safety problems or mismanagement. Leakage control clauses may incentivize doctors to keep patients within their own health systems, regardless of patients’ needs, while termination-without-cause clauses may threaten whistleblowers who raise ethical or quality concerns.
Other potentially troubling language includes defining “disruptive behavior” so broadly—with disruptive behavior being a cause for termination—that it could encompass disagreeing with management or publicly airing safety concerns. And noncompetes may work to impede patient access to certain specialties.
How’s group morale? There’s an index for that
CITING THE IMPACT that poor morale has on physician retention, a group of researchers has validated a new tool to measure hospitalist morale.
The hospital morale survey, which was tested among more than 100 hospitalists, is organized around five job factors: clinical, workload, leadership, appreciation and acknowledgement, and material rewards. It also asks about five additional items including family time, institutional climate, job security, autonomy and professional growth.
According to a study on the survey, each one-point increase in personal morale score is associated with an 85% decrease in the odds that a hospitalist intends to leave a job because of unhappiness. The authors noted that while annual turnover for all physicians is 6.8%, that of hospitalists is around 15%. Use of the survey, they wrote, can help groups target retention strategies.
The study was posted online last month by the Journal of Hospital Medicine. A copy of the index survey can be found online.
A troubling look at clinical-trial results
AN ANALYSIS of the publishing track record of 51 research powerhouses in the U.S. reveals this startling statistic: The results of almost half (44%) of all registered trials haven’t been published more than three years (and as many as seven) after those studies were completed.
Writing in the British Medical Journal in February, authors looked at academic centers with 40 or more completed interventional trials registered on ClinicalTrials.gov, a registry maintained by the National Institutes of Health, and completed between October 2007 and September 2010. Among the more than 4,300 trials identified, 23% had enrolled more than 100 patients and 50% were phase II through IV.
Study results indicate that those researchers disseminated results within 24 months of study completion for only 36% of registered studies, with dissemination rates ranging in individual academic centers from 16% to 55%.
The lack of timely reporting and publication,” the authors wrote, “fundamentally impairs the research enterprise … and threatens to compromise evidence based clinical decision-making.”
Should hospital security guards be armed?
A 2014 SURVEY found that 52% of medical centers had given their security guards handguns, while 47% of guards carried Tasers. Those statistics are helping fuel a debate over whether arming security guards in hospitals improves safety or poses a new threat.
A New York Times article published in February reported that at least one dozen episodes have taken place in the past several years in which patients have been shot or shocked by security personnel. Just about all those incidents involved psychiatric patients, two of whom died after being Tasered.
By comparison, security guards at Boston’s Massachusetts General Hospital carry only pepper spray, while those in New York public hospitals are armed with only plastic wrist restraints.
The article also noted that more off-duty police and military veterans are now filling security-guard positions in hospitals. Between 2012 and 2014, the article pointed out, health care facilities reported more than 10,000 incidents, most of which were directed at employees, and a 40% increase in violent crime.