Update in hospital medicine: Studies likely to affect inpatient practice in 2011
KEY POINTS
- Dabigatran (Pradaxa) will likely start to replace warfarin (Coumadin) both to prevent stroke in patients with atrial fibrillation and to prevent recurrent venous thromboembolism.
- Using a checklist during insertion of central venous catheters can decrease the rate of catheter-related bloodstream infections in the intensive care unit.
- The overall survival rate of patients who undergo cardiopulmonary resuscitation in the intensive care unit is approximately 16%; the rate is lower in patients who are receiving pressor drugs and higher in those with ventricular tachycardia or ventricular fibrillation.
- Patients lacking follow-up with a primary care physician within 30 days of discharge are at high risk of readmission and have a trend for longer length of hospital stay.
- Preoperative stress testing for patients undergoing noncardiac surgery should be done selectively, ie, in patients at high risk.
CASE CONTINUED: HE IS RESUSCITATED
P.G. is started on a 1-L fluid bolus but he remains hypotensive, necessitating a norepinephrine drip. He does well for about 6 hours, but in the middle of the night he develops ventricular tachycardia and ventricular fibrillation, and a code is called. He is successfully resuscitated, but the family is looking for prognostic information.
3. What are P.G.’s chances of surviving and leaving the hospital?
- 5%
- 8%
- 15%
- 23%
A registry of cardiopulmonary resuscitation
Tian et al5 evaluated outcomes in the largest registry of cardiopulmonary resuscitation to date. In this analysis, 49,656 adult patients with a first cardiopulmonary arrest occurring in an ICU between January 1, 2000, and August 26, 2008, were evaluated for their outcomes on pressors vs those not on pressors.
Other independent predictors of a lower survival rate were nonwhite race, mechanical ventilation, having three or more immediate causes of cardiopulmonary arrest, age 65 years or older, and cardiopulmonary arrest occurring at night or over the weekend.
Fortunately, for our patient, survival rates were higher for patients with ventricular tachycardia or fibrillation than with other causes of cardiopulmonary arrest: 22.6% for those on pressors (like our patient) and 40.7% for those on no pressors.
CASE CONTINUED: HE RECOVERS AND GOES HOME
P.G. makes a remarkable recovery and is now ready to go home. It is the weekend, and you are unable to schedule a follow-up appointment before his discharge, so you ask him to make an appointment with his PCP.
4. What is the likelihood that P.G. will be readmitted within 1 month?
- 5%
- 12%
- 20%
- 25%
- 30%
The importance of follow-up with a primary care physician
Misky et al,6 in a small study, attempted to identify the characteristics and outcomes of discharged patients who lack timely follow-up with a PCP. They prospectively enrolled 65 patients admitted to University of Colorado Hospital, an urban 425-bed tertiary care center, collecting information about patient demographics, diagnosis, payer source, and PCPs. After discharge, they called the patients to determine their PCP follow-up and readmission status. Thirty-day readmission rates and hospital length of stay were compared in patients with and without timely PCP follow-up (ie, within 4 weeks).
Patients lacking timely PCP follow-up were 10 times more likely to be readmitted (odds ratio [OR] = 9.9, P = .04): the rate was 21% in patients lacking timely PCP follow-up vs 3% in patients with timely PCP follow-up, P = .03. Lack of insurance was associated with lower rates of timely PCP follow-up: 29% vs 56% (P = .06), but did not independently increase the readmission rate or length of stay (OR = 1.0, P = .96). Index hospital length of stay was longer in patients lacking timely PCP follow-up: 4.4 days vs 6.3 days, P = 0.11.
Comment. Nearly half of the patients in this study, who were discharged from a large urban academic center, lacked timely follow-up with a PCP, resulting in higher rates of readmission and a nonsignificant trend toward longer length of stay. Timely follow-up is necessary for vulnerable patients.
Since the lack of timely PCP follow-up results in higher readmission rates and possibly a longer length of stay, a PCP appointment at discharge should perhaps be considered a core quality measure. This would be problematic in our American health care system, in which many patients lack health insurance and do not have a PCP.
A MAN UNDERGOING GASTRIC BYPASS SURGERY
A 55-year-old morbidly obese man (body mass index 45 kg/m2) with a history of type 2 diabetes mellitus, chronic renal insufficiency (serum creatinine level 2.1 mg/dL), hypercholesterolemia, and previous stroke is scheduled for gastric bypass surgery. His functional capacity is low, but he is able to do his activities of daily living. He reports having dyspnea on exertion and intermittently at rest, but no chest pain. His medications include insulin, atorvastatin (Lipitor), aspirin, and atenolol (Tenormin). He is afebrile; his blood pressure is 130/80 mm Hg, pulse 75, and oxygen saturation 97% on room air. His baseline electrocardiogram shows no Q waves.
5. Which of the following is an appropriate next step before proceeding to surgery?
- Echocardiography
- Cardiac catheterization
- Dobutamine stress echocardiography or adenosine thallium scanning
- No cardiac testing is necessary before surgery
