In the Literature

The Hospitalist. 2010 July;2010(07):

July 1, 2010|The Hospitalist

Rubin Bahuva, MD;Chadi Alraies, MD;Anuradha Ramaswamy, MD;Sudhir Manda, MD;Maria Giselle Velez, MD;Mital Patel, MD;Department OF

In This Edition

Literature at a Glance

A guide to this month’s studies

Effect of restrictive antibiotic policies on dosing timeliness
Desired consultation format and content
Risk of cancer associated with CT imaging
Bleeding, mortality with aspirin after peptic ulcer bleed
Diagnosis of lung cancer after pneumonia
Outcomes associated with hyponatremia
Patient awareness, interest in inpatient medication list
Monoclonal antibodies in C. difficile

Restrictive Antimicrobial Policy Delays Administration

Clinical question: Does the approval process for restricted on-formulary antimicrobials cause a significant delay in their administration?

Background: Widespread and often unwarranted, antimicrobial use in the hospital lends itself to the development of microbial resistance and increases overall costs. To curb such practices, many hospitals require subspecialty approval prior to dispensing select broad-spectrum antimicrobials. Though shown to improve outcomes, the impact of the approval process on the timeliness of antimicrobial administration remains to be seen.

Study design: Retrospective cohort study.

Setting: Tertiary-care university hospital.

Synopsis: The study included 3,251 inpatients with computerized orders for a “stat” first dose of any of 24 pre-selected, parenteral antimicrobials. Time lag (more than one hour, and more than two hours) to nursing documentation of drug administration was separately analyzed for restricted and unrestricted antimicrobials.

Delay of more than one hour was significantly higher for restricted antimicrobials with an odds ratio of 1.49 (95% CI; 1.23-1.82), while the odds ratio for a delay of more than two hours was 1.78 (95% CI, 1.39-2.21). Also, for restricted antimicrobials, the percentage of orders delayed for more than one hour was significantly different between daytime and nighttime (when the first dose was exempt from pre-approval) orders: 46.1% versus 38.8% (P<0.001). For unrestricted drugs, delay was uniform irrespective of time of day (36.4% of daytime and 36.6% of nighttime orders were delayed more than one hour). The effect of delay in drug administration on patient outcomes was not evaluated.

Though the approval process aims in part to affect resistance patterns and overall costs, this research highlights the need to minimize the delay in administration and probably skip the approval for the first dose in critically ill patients.

Bottom line: Antibiotic approval processes can delay their administration in hospitalized patients, but the effect of this delay on patient outcomes is not yet known.

Citation: Winters BD, Thiemann DR, Brotman DJ. Impact of a restrictive antimicrobial policy on the process and timing of antimicrobial administration. J Hosp Med. 2010;5(1):E41-45.

Clinical Shorts

AMONG NONINVASIVE TESTS, CT WAS BETTER THAN CARDIAC MRI TO RULE OUT CORONARY ARTERY DISEASE (CAD)

In a systematic review comparing CT or MRI to coronary angiography, CT was a better test to rule out CAD (pooled sensitivity 97.2% vs. 87.1%), especially at heart rate <60 and with newer machines.

Citation: Schuetz GM, Zacharopoulou NM, Schlattmann P, Dewey M. Meta-analysis: noninvasive coronary angiography using computed tomography versus magnetic resonance imaging. Ann Intern Med. 2010;152(3):167-177.

EARLY REPOLARIZATION PATTERN IN INFERIOR LEADS ASSOCIATED WITH WORSE CARDIAC OUTCOMES

In this community-based study of 10,864 middle-aged people, J point elevation in the inferior leads was a stronger predictor of death from cardiac causes than prolonged QTc or LVH.

Citation: Tikkanen JT, Anttonen O, Junttila MJ, et al. Long-term outcome associated with early repolarization on electrocardiography. N Engl J Med. 2009;361(26):2529-2537.

Physicians Uphold Tenets of Effective Consultation while Highlighting Some Newer Viewpoints

Clinical question: What key features of a consultation are most desirable for physicians?

Background: With new changes in healthcare delivery, the standardization offered by the electronic health record (EHR) system will undoubtedly be confronted by the heterogeneity of clinical consultations. Determination of the various characteristics considered essential for a consultation can help standardize the processes and improve the quality of communication.