Physician Reviews of Hospital Medicine-Related Research

The Hospitalist. 2013 June;2013(06):

June 1, 2013 | The Hospitalist

Jeffrey Ceresnak, MD ; Sanjay Galhotra, MD ; Valentina Goloborodko, MD, MPH ; Paul Martin, MD, MPH ; Andrea Porrovecchio, MD ; Martina Stehlikova, MD ; Will Southern, MD, MS, SFHM ; Albert Einstein College Of Medicine ; Montefiore Medical Center ; Bronx ; N.Y.

Background: Research has shown that EMR-based prediction tools can help identify real-time clinical deterioration in ward patients, but an intervention based on these computer-based alerts has not been shown to be effective.

Study design: Randomized controlled crossover study.

Setting: Eight adult medicine wards in an academic medical center in the Midwest.

Synopsis: There were 20,031 patients assigned to intervention versus control based on their floor location. Computerized alerts were generated using a prediction algorithm. For patients admitted to intervention wards, the alerts were sent to the charge nurse via pager. Patients meeting the alert threshold based on the computerized prediction tool had five times higher risk of ICU transfer, and nine times higher risk of death than patients not meeting the alert threshold. Intervention of charge nurse notification via pager did not result in any significant change in length of stay (LOS), ICU transfer, or mortality. Charge nurses in the intervention group were supposed to alert a physician after receiving the computer alert, but the authors did not measure how often this occurred.

Bottom line: A real-time EMR-based prediction tool accurately predicts higher risk of ICU transfer and death, as well as LOS, but a floor-based intervention to alert the charge nurse in real time did not lead to better outcomes.

Citation: Bailey TC, Chen Y, Mao Y, et al. A trial of a real-time alert for clinical deterioration in patients hospitalized on general medicine wards. J Hosp Med. 2013 Feb 25. doi: 10.1002/jhm.2009 [Epub ahead of print].

Hypothermia Protocol and Cardiac Arrest

Clinical question: Is mild therapeutic hypothermia (MTH) following cardiac arrest beneficial and safe?

Background: Those with sudden cardiac arrest often have poor neurologic outcome. There are some studies that show benefit with hypothermia, but information on safety is limited.

Study design: Meta-analysis.

Setting: Europe, the United Kingdom, the U.S., Canada, Japan, and South Korea.

Synopsis: This study pooled data from 63 studies that looked at MTH protocols in the setting of comatose patients as a result of cardiac arrest. The end points included mortality and any complication potentially attributed to the MTH.

When restricting the analysis to include only randomized controlled trials, MTH was associated with decreased risk of in-hospital mortality (RR=0.75, 95% CI: 0.62-0.92), 30-day mortality (RR=0.61, 95% CI 0.45-0.81), and six-month mortality (RR=0.73, 95% CI 0.61-0.88). MTH was associated with increased risk of arrhythmia (RR=1.25, 95% CI: 1.00-1.55) and hypokalemia (RR=2.35, 95% CI: 1.35-4.11); all other complications were similar between groups.

There were inconsistent results regarding benefit in pediatric patients, as well as comatose patients with non-ventricular fibrillation (non-v-fib) arrest (i.e. asystole or pulseless electrical activity).

Bottom line: Mild therapeutic hypothermia can improve survival of comatose patients after v-fib cardiac arrest and is generally safe.

Citation: Xiao G, Guo Q, Xie X, et al. Safety profile and outcome of mild therapeutic hypothermia in patients following cardiac arrest: systematic review and meta-analysis. Emerg Med J. 2013;30:90-100.

Clinical Shorts

DAILY CHLORHEXIDINE BATHING REDUCES INFECTIONS

In eight ICUs and one bone marrow transplant unit, daily bathing with chlorhexidine-impregnated washcloths reduced the acquisition of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE), as well as the rate of hospital-acquired infections.

Citation: Climo MW, Yokoe DS, Warren DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368:533-542.

PREOPERATIVE BLOOD TRANSFUSIONS MIGHT BE BENEFICIAL IN PATIENTS WITH SICKLE CELL DISEASE

A prospective multicenter randomized study showed lower incidence of perioperative complications and serious adverse events—mainly acute chest syndrome—in sickle cell patients who were transfused prior to low- or moderate-risk surgery.

Citation: Howard J, Malfroy M, Llewelyn C, et al. The transfusion alternatives preoperatively in sickle cell disease (TAPS) study: a randomized, controlled, multicenter clinical trial. Lancet. 2013;381:930-938.

IMPACT OF DELIRIUM IN THE ICU

Meta-analysis suggests that delirium in critically ill patients is associated with increased mortality, complications, time on the mechanical ventilator, and length of stay in the hospital and ICU.

Citation: Zhang Z, Pan L, Ni H. Impact of delirium on clinical outcome in critically ill patients: a meta-analysis. Gen Hosp Psychiatry. 2013;(35):105-111.

BENEFIT OF BETA-BLOCKERS IN PATIENTS WITH HEART FAILURE AND REDUCED EJECTION FRACTION IS DUE TO CLASS EFFECT

Meta-analysis of 21 trials involving atenolol, bisoprolol, bucindolol, carvedilol, metoprolol, and nebivolol concluded that no beta-blocker was superior to another in reducing mortality, but that reduced mortality instead reflected a class effect.

Citation: Chatterjee S, Biondi-Zoccai G, Abbate A, et al. Benefits of beta-blockers in patients with heart failure and reduced ejection fraction: network meta-analysis. BMJ. 2013;346:f55.

COMBINED USE OF FLUOROQUINOLONES AND AZOLES MAY REQUIRE MONITORING FOR QTC PROLONGATION

Retrospective case series analysis of patients with hematologic malignancies demonstrated that combination therapy with fluoroquinolones and azoles caused clinically significant QTc prolongation (>30 ms change from baseline or a follow-up QTc >470 ms) in 22% of patients.

Citation: Zeuli JD, Wilson JW, Estes LL. Effect of combined fluoroquinolone and azole use on QT prolongation in hematology patients. Antimicrob Agents Chemother. 2013;57(3):1121-1127.