Postdischarge Test Results, Acute Renal Failure, Diagnosing PE

The Hospitalist. 2005 November;2005(11):

November 1, 2005 | The Hospitalist

Discussion: Roy and his coauthors attempted to quantify the prevalence of potentially actionable laboratory tests available after discharge and published rather striking findings. Up to half of all patients have some tests pending at discharge and up to 10% of these require some physician action. More frighteningly, outpatient MDs are generally unaware of these tests creating a huge gap in patient safety in the transition back to outpatient care.

How can we do this better? SHM and the Society for General Internal Medicine have convened a Continuity of Care Task Force and found poor communication with outpatient providers was a common and potentially dangerous problem. They outlined the best practices for the discharge of patients to ensure safety as well as maximize patient and physician satisfaction. Their recommendations are available on the SHM Web site. All hospitalists and institutions should be aware of the potential for missed results and put systems in place, electronic and otherwise, to create an appropriate safety net for our discharged patients.

Mandatory infectious disease consultation prior to discharge for patients scheduled to received outpatient parenteral antibiotic therapy resulted in substantial cost savings, and streamlined and more appropriate antibiotic regimens without any adverse impact on outcomes.

Sharma R, Loomis W, Brown RB. Impact of mandatory inpatient infectious disease consultation on outpatient parenteral antibiotic therapy. Am J Med Sci. 2005;330(2):60.

Background: As the pressure to limit healthcare costs by reducing inpatient length of stay has increased, the use of outpatient parenteral antibiotic therapy has grown. When employed appropriately, home intravenous antibiotic therapy has consistently resulted in cost savings without compromising patient outcomes. As with other healthcare advances, there is some fear that outpatient parenteral antibiotic treatment will be overused or misused, limiting the cost savings or putting patients at risk.

Methods: A single academic medical center instituted mandatory infectious disease consultation on all patients referred to discharge coordinators with plans for outpatient IV antibiotic treatment. The infectious disease consultants helped to determine the need for outpatient parenteral therapy and antibiotic choice. All patients were followed for 30 days.

Results: Over the one-year study period, 44 cases received mandatory infectious disease consultation. Thirty-nine (89%) of these had some change in antibiotic regimen after the consultation. Seventeen patients (39%) were switched to oral antibiotics, 13 (30%) had a change in infectious disease antibiotic, and 5 (11%) had a change in antibiotic dose.

Skin and skin structure and intra-abdominal infections were the most common diagnoses for which antibiotics were changed; a typical change was from intravenous piperacillin/tazobactam to an oral fluoroquinolone plus oral anaerobic coverage. At 30-day follow-up, 98% of patients finished their courses without relapse or complication. The overall costs savings was $27,500 or $1,550 per patient consulted upon.

Discussion: Although from a small, nonrandomized, single-institution study, the results are impressive. Mandatory infectious disease consultation prior to discharge for patients scheduled to received outpatient parenteral antibiotic therapy resulted in substantial cost savings, and streamlined and more appropriate antibiotic regimens without any adverse impact on outcomes. Hospitalists should take two things away from this study: 1) consider consulting infection disease specialists on all patients who might be candidates for home IV antibiotics and 2) be aware that many skin and skin tissue and intra-abdominal infections can often be treated with oral therapy. TH

Classic Literature

The Sanocrysin Story

Amberson JB, McMahon BT, Pinner M. A clinical trial of sanocrysin in pulmonary tuberculosis. Am Review Tuberculosis. 1931;24:401.

Background: In 1931, the optimal treatment for pulmonary mycobacterium tuberculosis was unknown. Many different compounds and chemicals were tried, most with variable success.

Methods: J. Burns Amberson, MD, and colleagues at the Maybury Sanatorium in Detroit organized a clinical trial of sanocrysin (sodium-gold-thiosulfate) in the treatment of pulmonary tuberculosis. Twenty-four stable inpatients were chosen and on the basis of clinical, radiographic, and laboratory findings they were individually matched in pairs and divided into two comparable groups of 12 patients each.

By a flip of the coin, one group received gradually increasing sanocrysin injections and the other placebo (saline injection). Of note, all patients were on bed rest for 30 days prior to the study and blinded to their treatment group (the investigators and head nurse were not blinded). Patients received biweekly chest examinations, daily sputum weights, sputum microscopic examination every two weeks, and overall symptoms were followed for the study period.

Results: Overall, after treatment the two groups were similar in terms of respiratory symptoms (i.e., cough, dyspnea), daily sputum volume, sputum bacillary content, or pulmonary physical exam findings. In fact, some of the sanocrysin patients became worse. In the sanocrysin-treated group, 7/12 developed rash, 9/12 developed conjunctivitis, and 11/12 had anorexia, nausea, vomiting, and diarrhea. Additionally, all 12 of the sanocrysin-treated patients showed evidence of acute tubular necrosis and albuminuria. None of the placebo-treated patients had gastrointestinal symptoms or renal dysfunction. One patient given sanocrysin died of acute liver failure thought to be related to the drug.

Discussion: In 1924 H. Mollgaard MD, published the results of his study of sanocrysin and claimed the substance has a curative effect on pulmonary tuberculosis. The ingeniously designed clinical trial by Amberson and colleagues takes the first step in debunking this claim. Sanocrysin showed no clinical or laboratory benefit over placebo in the treatment of pulmonary tuberculosis but had incredibly high rates of toxicity, likely from heavy metal poisoning, and probably lead to one patient death. The authors state that because of the lack of definite evidence of benefit and clear evidence of harm, the use of sanocrysin is not justified.

Prior to the 1930s and 1940s, new treatments in medicine were judged to be effective if a single physician reported success in a case series without any control group. This landmark paper published in 1931 was one of the first to attempt to randomize patients to treatment versus placebo. Patients were matched individually and placed into two groups and, amazingly, these groups were randomized through the use of a coin toss.

Clearly, the study is limited in that matching subjects exactly is impossible and because the study was small. Yet, the striking rate of toxic side effects in the sanocrysin group argued strongly against its routine use. This paper didn’t do much to change the management of tuberculosis, but it attempted to remove selection bias and randomness in outcomes in clinical trials, taking one of the first steps toward modern evidence-based medicine.