Kristin Furfari, MD

Clinical question: What is the impact, and sustainability, of chlorhexidine bathing on central-venous-catheter-associated bloodstream infections?

Background: Chlorhexidine bathing has been associated with reductions in healthcare-associated bloodstream infections, including vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus. No prospective studies have evaluated the impact and sustainability of chlorhexidine bathing.

Study design: Prospective, three-phase study.

Setting: Medical-surgical ICUs and respiratory-care units at five New York hospitals.

Synopsis: In the pre-intervention phase (six to nine months, 1,808 admissions), patients were bathed with soap and water or nonmedicated bathing cloths. In the intervention phase (eight months, 1,832 admissions), patients were bathed with 2% chlorhexidine cloths. In the post-intervention phase (12 months, 2,834 admissions), chlorhexidine bathing was continued without oversight by researchers.

During the intervention phase, there were significantly fewer central-venous-catheter-associated bloodstream infections (2.6/1,000 catheter days vs. 6.4/1,000 pre-intervention). The reductions in bloodstream infections were sustained during the post-intervention period (2.9/1,000 catheter days). Compliance with chlorhexidine bathing was 82% and 88% during the intervention and post-intervention phases, and was well tolerated by the patients.

Limitations of this study include lack of patient-specific data and severity of illness data, as well as lack of randomization and blinding. Although not evaluated in this study, the savings associated with decreased bloodstream infections likely outweigh the cost of chlorhexidine bathing.

Bottom line: Chlorhexidine bathing is a well-tolerated, sustainable intervention that significantly reduces central-venous-catheter-associated bloodstream infections.

Citation: Montecalvo MA, McKenna D, Yarrish R, et al. Chlorhexidine bathing to reduce central venous catheter-associated bloodstream infection: impact and sustainability.Am J Med. 2012;125(5):505-511.

For more physician reviews of recent HM-relevant literature, visit our website.

Clinical question: What is the impact, and sustainability, of chlorhexidine bathing on central-venous-catheter-associated bloodstream infections?

Background: Chlorhexidine bathing has been associated with reductions in healthcare-associated bloodstream infections, including vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus. No prospective studies have evaluated the impact and sustainability of chlorhexidine bathing.

Study design: Prospective, three-phase study.

Setting: Medical-surgical ICUs and respiratory-care units at five New York hospitals.

Synopsis: In the pre-intervention phase (six to nine months, 1,808 admissions), patients were bathed with soap and water or nonmedicated bathing cloths. In the intervention phase (eight months, 1,832 admissions), patients were bathed with 2% chlorhexidine cloths. In the post-intervention phase (12 months, 2,834 admissions), chlorhexidine bathing was continued without oversight by researchers.

During the intervention phase, there were significantly fewer central-venous-catheter-associated bloodstream infections (2.6/1,000 catheter days vs. 6.4/1,000 pre-intervention). The reductions in bloodstream infections were sustained during the post-intervention period (2.9/1,000 catheter days). Compliance with chlorhexidine bathing was 82% and 88% during the intervention and post-intervention phases, and was well tolerated by the patients.

Limitations of this study include lack of patient-specific data and severity of illness data, as well as lack of randomization and blinding. Although not evaluated in this study, the savings associated with decreased bloodstream infections likely outweigh the cost of chlorhexidine bathing.

Bottom line: Chlorhexidine bathing is a well-tolerated, sustainable intervention that significantly reduces central-venous-catheter-associated bloodstream infections.

Citation: Montecalvo MA, McKenna D, Yarrish R, et al. Chlorhexidine bathing to reduce central venous catheter-associated bloodstream infection: impact and sustainability.Am J Med. 2012;125(5):505-511.

For more physician reviews of recent HM-relevant literature, visit our website.

Clinical question: What is the impact, and sustainability, of chlorhexidine bathing on central-venous-catheter-associated bloodstream infections?

Background: Chlorhexidine bathing has been associated with reductions in healthcare-associated bloodstream infections, including vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus. No prospective studies have evaluated the impact and sustainability of chlorhexidine bathing.

Study design: Prospective, three-phase study.

Setting: Medical-surgical ICUs and respiratory-care units at five New York hospitals.

Synopsis: In the pre-intervention phase (six to nine months, 1,808 admissions), patients were bathed with soap and water or nonmedicated bathing cloths. In the intervention phase (eight months, 1,832 admissions), patients were bathed with 2% chlorhexidine cloths. In the post-intervention phase (12 months, 2,834 admissions), chlorhexidine bathing was continued without oversight by researchers.

During the intervention phase, there were significantly fewer central-venous-catheter-associated bloodstream infections (2.6/1,000 catheter days vs. 6.4/1,000 pre-intervention). The reductions in bloodstream infections were sustained during the post-intervention period (2.9/1,000 catheter days). Compliance with chlorhexidine bathing was 82% and 88% during the intervention and post-intervention phases, and was well tolerated by the patients.

Limitations of this study include lack of patient-specific data and severity of illness data, as well as lack of randomization and blinding. Although not evaluated in this study, the savings associated with decreased bloodstream infections likely outweigh the cost of chlorhexidine bathing.

Bottom line: Chlorhexidine bathing is a well-tolerated, sustainable intervention that significantly reduces central-venous-catheter-associated bloodstream infections.

Citation: Montecalvo MA, McKenna D, Yarrish R, et al. Chlorhexidine bathing to reduce central venous catheter-associated bloodstream infection: impact and sustainability.Am J Med. 2012;125(5):505-511.

For more physician reviews of recent HM-relevant literature, visit our website.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Prediction tool for neurological outcomes after in-hospital cardiac arrest
2. Radiation exposure in integrated healthcare systems, 1996-2010
3. Postoperative troponin predicts 30-day mortality
4. Clinical prediction model of mortality in acute heart failure
5. Indwelling pleural catheter vs. talc pleurodesis via chest tube
6. Early surgery for high-risk, native-valve endocarditis patients
7. Risk factors after ED visit for syncope
8. Acute hyperglycemia in CAP patients
9. Hospital delirium associated with cognitive decline, institutionalization, and death
10. Seven-day ciprofloxacin effective against acute pyelonephritis
11. Advance directives in community patients with heart failure
12. Chlorhexidine bathing effective against CVC-associated bloodstream infections
13. Simulation training improves lumbar puncture skills
14. PCP referrals to hospitals and publicly reported data
15. Medication reconciliation best practices

Prediction Tool Validated for Prognosticating Favorable Neurological Outcome after In-Hospital Cardiac Arrest

Clinical question: Does the Cardiac Arrest Survival Post Resuscitation In-Hospital (CASPRI) score accurately predict favorable neurological outcomes?

Background: Previous cardiac arrest prediction models have been focused on survival to discharge without consideration of neurological status and have not been translated into valid bedside prognostication tools. Neurologic prognosis can assist patients, families, and physicians in decisions about continued goals of care post-arrest.

Study design: Retrospective cohort study.

Setting: Acute-care hospitals.

Synopsis: Using the Get with the Guidelines Resuscitation Registry, 551 hospitals identified 42,957 patients who were successfully resuscitated from an in-hospital cardiac arrest from January 2000 to October 2009. Researchers developed a simple prediction tool for favorable neurological outcomes (defined as “no” or “moderate” neurological disability) at discharge. The 11 predictors used to calculate the CASPRI score are age; time to defibrillation; pre-arrest neurological status; hospital location; duration of resuscitation; and pre-arrest comorbidities: mechanical ventilation, renal insufficiency, hepatic insufficiency, sepsis, malignancy,

and hypotension.

Rates of favorable neurological outcome were similar between derivation cohort (24.6%) and validation cohort (24.5%). The model had excellent discrimination with a C score of 0.80. Probability of favorable neurological survival ranged from 70.7% in the top decile of patients (CASPRI <10) and 2.8% in bottom decile (CASPRI ≥ 28).

This tool is not generalizable to patients with out-of-hospital arrest or undergoing therapeutic hypothermia.

Bottom line: CASPRI is a simple bedside tool validated to estimate probability of favorable neurological outcome after in-hospital cardiac arrest.

Citation: Chan PS, Spertus JA, Krumholz HA, et al. A validated prediction tool for initial survivors in in-hospital cardiac arrest. Arch Intern Med. 2012;172(12):947-953.

Increased Use of Radiologic Imaging and Associated Radiation Exposure in Integrated Healthcare Systems, 1996-2010

Clinical question: How much has imaging utilization and associated radiation exposure increased over 15 years in integrated healthcare systems independent of financial incentives in a fee-for-service system?

Background: Use of diagnostic imaging has increased significantly within fee-for-service healthcare models. The associated radiation exposure has increased the risk of radiation-induced malignancies. Little is known about the pattern of imaging use in integrated healthcare systems without the financial incentives seen in other models of care.

Study design: Retrospective cohort study.

Setting: Six integrated healthcare systems in the U.S.

Synopsis: The number of diagnostic imaging studies performed and estimated radiation exposure were determined from analysis of electronic medical records from member patients enrolled in health systems in the HMO Research Network from 1996 to 2010. Annual increases in use of advanced diagnostics were noted in CT (7.8% annual growth), MRI (10%), ultrasound (3.9%), and PET (57%) studies.

Increased CT use over the 15-year study period resulted in increased radiation exposure, doubling mean per capita effective dose (1.2 mSv to 2.3 mSv), as well as those receiving high exposure (1.2% to 2.5%) and very high exposure (0.6% to 1.4%).

The increased imaging use and radiation exposure among HMO enrollees was similar to that of fee-for-service Medicare patients in previous studies.

Bottom line: There is a significant increase in use of diagnostic imaging studies and associated radiation exposure among integrated healthcare system enrollees from 1996 to 2010, similar to patients in fee-for-service health plans.

Citation: Smith-Bindman R, Miglioretti DL, Johnson E, et al. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010. JAMA. 2012;307(22):2400-2409.

Postoperative Troponin Predicts 30-Day Mortality

Clinical question: Does postoperative peak troponin level predict 30-day mortality in patients undergoing noncardiac surgery?

Background: The use of postoperative peak troponin levels in predicting 30-day mortality for patients undergoing noncardiac surgery has not been studied extensively. Identifying patients at high risk for death following noncardiac surgery could facilitate appropriate postoperative care and improve survival.

Study design: Prospective cohort study.

Setting: International university and nonuniversity hospitals.

Synopsis: The Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study is a large, international, multicenter, prospective cohort study designed to evaluate the major complications of noncardiac surgery. More than 15,100 patients ages 45 and older requiring at least an overnight hospitalization were enrolled following noncardiac surgery.

Peak troponin measurements during the first three postoperative days of 0.01 ng/ml or less, 0.02 ng/ml, 0.03 ng/ml to 0.29 ng/ml, and 0.3 ng/ml or greater had 30-day mortality rates of 1.0%, 4.0%, 9.3%, and 16.9%, respectively.

This study demonstrates the sensitivity of troponin measurement for predicting postoperative 30-day mortality in patients undergoing noncardiac surgery. The study does not address interventions based on an increased postoperative troponin level. Future studies might investigate postoperative modifiable risk factors.

Bottom line: Postoperative peak troponin level predicts 30-day mortality in patients undergoing noncardiac surgery.

Citation: Devereaux PJ, Chan MT, Alonso-Coello P, et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA. 2012;307(21):2295-2304.

Clinical Prediction Model of Mortality in Acute Heart Failure

Clinical question: Can a clinical prediction model accurately risk-stratify patients presenting to the ED with acute heart failure?

Background: Accurately prognosticating mortality is essential when determining whether to hospitalize or discharge patients presenting to the ED with acute heart failure. Evidence-based clinical prediction models enable physicians to risk-stratify patients and optimize care.

Study design: Retrospective cohort study.

Setting: Multicenter study of 86 hospitals in Ontario, Canada.

Synopsis: Data collected from 12,591 patients who presented to EDs with acute heart failure in Ontario were analyzed. A clinical prediction model of seven-day mortality of discharged and hospitalized patients was derived and validated. The Emergency Heart Failure Mortality Risk Grade (EHMRG) found an increased mortality based on higher triage heart rate, lower triage systolic blood pressure, initial oxygen saturation, and elevated troponin levels. This model uses readily available data collected in ED visits. The high-risk EHMRG score predicted about 8% seven-day mortality versus 0.3% in the low-risk score.

This model was not applied to chronic heart failure, did not utilize left ventricular function, and does not differentiate between systolic and diastolic heart failure.

Bottom line: The Emergency Heart Failure Mortality Risk Grade predicts seven-day mortality in acute heart failure in the emergent setting.

Citation: Lee DS, Stitt A, Austin PC, et al. Prediction of heart failure mortality in emergent care: a cohort study. Ann Intern Med. 2012;156(11):767-775.

Indwelling Pleural Catheter Is as Effective as Talc Pleurodesis Via Chest Tube in Relieving Dyspnea in Patients with Malignant Pleural Effusion

Clinical question: Is indwelling pleural catheter (IPC) as effective as chest tube and talc pleurodesis (talc) in improving dyspnea from malignant pleural effusion in patients who had no previous pleurodesis?

Background: Despite guidelines recommending chest tube insertion with pleurodesis as a first-line treatment for symptom palliation from malignant pleural effusion, there has been no randomized trial comparing indwelling pleural catheter with chest tube and talc pleurodesis.

Study design: Open-label, randomized controlled trial.

Setting: Seven hospitals in the United Kingdom.

Synopsis: One hundred six patients with malignant pleural effusion were randomized to undergo either IPC or talc treatment, and their daily mean dyspnea was measured. There was a clinically significant improvement of dyspnea in both IPC and talc groups over the first 42 days of the trial, without any significant difference in dyspnea between the two groups. After six months, researchers found a clinically significant decrease in dyspnea in the IPC group compared with the talc group. Chest pain and global quality of life were improved and were similar in both groups throughout the trial period. Length of hospital stay was significantly shorter in the IPC group compared with the talc group, but more patients in the IPC group experienced adverse events.

Bottom line: Indwelling pleural catheter is as effective as talc pleurodesis in reliving dyspnea from malignant pleural effusion; however, IPC is associated with increased adverse events despite shorter length of hospital stay.

Citation: Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs. chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383-2389.

Early Surgery Better than Conventional Treatment in High-Risk Native-Valve Endocarditis

Clinical question: Is early cardiac surgery better than conventional treatment for patients with left-sided, native-valve, infective endocarditis?

Background: Although guidelines strongly recommend early surgery for patients with infective endocarditis and congestive heart failure, the timing of surgery for patients with large vegetations and high risk of embolism without heart failure symptoms remains controversial.

Study design: Prospective, randomized trial.

Setting: Two medical centers in South Korea.

Synopsis: Seventy-six patients with left-sided, native-valve, infective endocarditis with a high risk of embolism (defined as vegetation with a diameter greater than 10 mm or severe mitral or aortic valve disease) were randomized to undergo early surgery (within 48 hours of enrollment) or conventional treatment (antibiotic therapy and surgery only if complications required urgent surgery). The primary outcome of composite in-hospital death or

clinical embolic events within six weeks of the trial occurred in only one patient in the early surgery group, compared with nine patients in the conventional group (hazard ratio 0.10, 95% CI, 0.01-0.82, P=0.03).

There was no difference in all-cause mortality at six months between the two groups, but the rate of composite endpoint of death from any cause, embolic events, or recurrence of infective endocarditis at six months was significantly lower in the early surgery group compared with the conventional group.

Bottom line: Early cardiac surgery for patients with left-sided, native-valve infective endocarditis with a high risk of embolism significantly improved the composite outcome of all-cause mortality, embolic events, or recurrence of endocarditis compared with the conventional therapy.

Citation: Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med. 2012;366(26):2466-2473.

Risk Factors for Short-Term Mortality after Emergency Department Visit for Syncope

Clinical question: What are the risk factors for short-term mortality after an ED evaluation for syncope or near-syncope?

Background: Syncope accounts for 1% to 2% of all ED visits and an equal number of hospital admissions. The risk of death after an ED visit for syncope is poorly understood, resulting in frequent hospital admissions.

Study design: Retrospective cohort study.

Setting: EDs in Southern California.

Synopsis: Authors evaluated 23,951 ED visits resulting in syncope as sole primary diagnosis. Age was identified as the most significant risk factor for short-term mortality. Cumulative survival data revealed that more than 1% of patients 60 or older died by 30 days. There were 215 deaths (2.84%) in patients hospitalized from the ED and 66 deaths (0.45%) among patients not hospitalized.

Pre-existing comorbidities significantly associated with increased mortality included heart failure (HR=14.3 in ages 18-53; HR=3.09 in ages 60-79; HR=2.34 in ages 80-plus), diabetes (HR=1.49), seizure (HR=1.65), dementia (HR=1.41), and a recent prior visit for syncope (HR=1.86). The risk of death by 30 days was less than 0.2% in patients under 60 without heart failure and more than 2.5% in patients of all ages with heart failure.

Bottom line: After an ED visit for syncope, patients with a history of heart failure and patients 60 and older have a significantly increased risk of short-term mortality.

Citation: Derose SF, Gabayan GZ, Chiu VY, Sun BC. Patterns and preexisting risk factors of 30-day mortality after a primary discharge diagnosis of syncope or near syncope. Acad Emerg Med. 2012;19(5):488-496.

Acute Hyperglycemia Associated with Increased Mortality in Community-Acquired Pneumonia

Clinical question: In patients admitted to the hospital for community-acquired pneumonia, is serum glucose level on admission associated with mortality?

Background: Some retrospective studies have shown an association between alterations in serum glucose levels or pre-existing diabetes and higher mortality due to infections, while other studies have shown no clear association.

Study design: Multicenter, prospective cohort study.

Setting: Hospitals and private practices in Germany, Switzerland, and Austria.

Synopsis: Prospective data from 6,891 patients were included in the analysis. Patients without diabetes and normal serum glucose levels had the lowest mortality after 90 days. Patients without diabetes but with mild acute hyperglycemia (108 mg/dL to 198 mg/dL) had a significantly increased risk of death at 90 days (HR 1.56), and patients without diabetes but with more severe acute hyperglycemia (over 252 mg/dL) had an even higher risk of death at 90 days (HR 2.37).

The 90-day mortality rate was significantly higher in patients with pre-existing diabetes (HR 2.47), although this was not affected by serum glucose levels on admission.

Bottom line: Acute hyperglycemia, as well as pre-existing diabetes, was associated with an increased risk of 90-day mortality in patients with community acquired pneumonia.

Citation: Lepper PM, Ott S, Nüesch E, et al. Serum glucose levels for predicting death in patients admitted to hospital for community acquired pneumonia: prospective cohort study. BMJ. 2012;344:e3397.

Hospital Delirium Associated with Cognitive Decline, Institutionalization, and Death

Clinical question: What is the risk of subsequent cognitive decline, institutionalization, or death due to delirium in patients with dementia?

Background: Patients suffering delirium during hospitalization can suffer additional cognitive decline. Whether this is due to additional damage from the delirium state or reflects pre-existing cognitive vulnerability remains uncertain.

Study design: Prospective analysis of a cohort of Alzheimer’s patients.

Setting: Massachusetts community-based disease registry.

Synopsis: The analysis compared nonhospitalized individuals to patients hospitalized with, and without, delirium. In 771 individuals with dementia, at least one adverse outcome (including cognitive decline, institutionalization, or death) occurred in 32% of those not hospitalized, 55% of those hospitalized without delirium, and 79% of those hospitalized with delirium. Even after adjusting for confounders, hospitalization increased the risk for each of the adverse outcomes; the highest risk was in those with delirium.

Among hospitalized patients, the authors estimated 1 in 5 cases of cognitive decline, 1 in 7 institutionalizations, and 1 in 16 deaths were attributable to delirium. Some of the attributed risk could be the result of residual confounding from unmeasured variables, limiting conclusions of causality. Despite these limitations, this study supports the hypothesis that delirium prevention measures could improve important patient outcomes.

Bottom line: Hospitalization is associated with high rates of adverse outcomes in elderly patients with dementia, the worst of which occurs in those who experience delirium.

Citation: Fong TG, Jones RN, Marcantonio ER, et al. Adverse outcomes after hospitalization and delirium in persons with Alzheimer disease. Ann Int Med. 2012;156:848-856.

In Acute Pyelonephritis, a Seven-Day Course of Ciprofloxacin is Effective in Obtaining Clinical Cure

Clinical question: What is the efficacy of ciprofloxacin for seven days compared with 14 days in women with community-acquired acute pyelonephritis?

Background: Community-acquired acute pyelonephritis is a common and sometimes serious infection in women. In an era of increasing antibiotic resistance worldwide, it is prudent to reduce antibiotic utilization. There are limited controlled trials to assess the optimum duration of antibiotic treatment for this common infection.

Study design: Prospective, randomized, double-blind, noninferiority trial.

Setting: Twenty-one infectious-disease centers in Sweden.

Synopsis: Researchers randomly assigned 284 women 18 or older with a presumptive diagnosis of acute pyelonephritis to ciprofloxacin treatment for seven or 14 days. The primary endpoint was clinical and bacteriological cure 10 to 14 days after the completion of the treatment regimen. Short-term clinical cure occurred in 97% of the patients treated for seven days and 96% treated for 14 days. Long-term follow-up showed cumulative efficacy of 93% in each group. Both regimens were well tolerated.

Patients in this study had a low occurrence of complicated (9%) and recurrent (13%) infections. Whether short courses of antibiotics are effective in more complicated infections cannot be ascertained from this study. Also, the high cure rate obtained with a seven-day course of ciprofloxacin should not be extrapolated to other classes of antibiotics. Fluoroquinolones, such as ciprofloxacin, are recommended as first-line agents for empiric oral treatment of acute pyelonephritis if the resistance rate of the uropathogens remains lower than 10%; however, there is growing evidence that E. coli strains are becoming increasingly resistant to ciprofloxacin, limiting its usefulness.

Bottom line: Acute pyelonephritis in women can be treated successfully and safely with a seven-day course of ciprofloxacin, in areas with low ciprofloxacin resistance.

Citation: Sandberg T, Skoog G, Hermansson AB, et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomized, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet. 2012;380:484-490.

Advance Directives in Community Patients with Heart Failure

Clinical question: How prevalent are advance directives in heart-failure patients, and does a completed advance directive decrease end-of-life resource use (hospitalizations, ICU admissions, mechanical ventilation)?

Background: Heart failure is a common chronic and fatal disease. End-of-life care in heart-failure patients is associated with extremely high healthcare utilization. Heart failure guidelines recommend completing advance directives in all patients.

Study design: Population-based longitudinal cohort study.

Setting: Rochester Epidemiology Project in Olmstead County, Minn.

Synopsis: Investigators enrolled 608 patients presenting with heart failure between October 2007 and October 2011. At the time of enrollment, only 41% of the patients had existing advance directives. Independent predictors of advance directive completion included older age, history of malignancy, and renal dysfunction.

After a mean follow-up of 1.8 years, 164 patients (27%) had died. Among those patients, 106 had an advance directive (64.6%) at time of death—75 had an advance directive at the time of enrollment and another 31 completed an advance directive after enrollment.

Twenty-five patients (23.6%) specified DNR/DNI and another 39 (36.8%) denoted limitations on aggressiveness of care if death was imminent. Among the patients who died, 88 (53.7%) were hospitalized in the last month of their life and 50 (30.5%) died in the hospital. There was no difference in hospitalizations between those with an advance directive specifying limits and those who did not specify limits (OR 1.26, 95% CI 0.64-2.48). However, those with an advance directive specifying limits were less frequently mechanically ventilated (OR 0.26, 95% CI 0.06-0.88), and there was a trend toward them being less frequently admitted into the ICU (OR 0.45, 95% CI 0.16-1.29).

Bottom line: Less than half of community patients with heart failure had an advance directive, and many of these failed to address end-of-life decisions. Patients with an advance directive that specified limits in care were less likely to receive mechanical ventilation.

Citation: Dunlay SM, Swetz KM, Mueller PS, Roger VL. Advance directives in community patients with heart failure. Circ Cardiovasc Qual Outcomes. 2012;5:283-289.

Chlorhexidine Bathing Associated with Significant, Sustainable Reductions in Central-Venous-Catheter-Associated Bloodstream Infection

Clinical question: What is the impact, and sustainability, of chlorhexidine bathing on central-venous-catheter-associated bloodstream infections?

Background: Chlorhexidine bathing has been associated with reductions in healthcare-associated bloodstream infections, including vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus. No prospective studies have evaluated the impact and sustainability of chlorhexidine bathing.

Study design: Prospective, three-phase study.

Setting: Medical-surgical ICUs and respiratory-care units at five New York hospitals.

Synopsis: In the pre-intervention phase (six to nine months, 1,808 admissions), patients were bathed with soap and water or nonmedicated bathing cloths. In the intervention phase (eight months, 1,832 admissions), patients were bathed with 2% chlorhexidine cloths. In the post-intervention phase (12 months, 2,834 admissions), chlorhexidine bathing was continued without oversight by researchers.

During the intervention phase, there were significantly fewer central-venous-catheter-associated bloodstream infections (2.6/1,000 catheter days vs. 6.4/1,000 pre-intervention). The reductions in bloodstream infections were sustained during the post-intervention period (2.9/1,000 catheter days). Compliance with chlorhexidine bathing was 82% and 88% during the intervention and post-intervention phases, and was well tolerated by the patients.

Limitations of this study include lack of patient-specific data and severity of illness data, as well as lack of randomization and blinding. Although not evaluated in this study, the savings associated with decreased bloodstream infections likely outweigh the cost of chlorhexidine bathing.

Bottom line: Chlorhexidine bathing is a well-tolerated, sustainable intervention that significantly reduces central-venous-catheter-associated bloodstream infections.

Citation: Montecalvo MA, McKenna D, Yarrish R, et al. Chlorhexidine bathing to reduce central venous catheter-associated bloodstream infection: impact and sustainability. Am J Med. 2012;125(5):505-511.

Simulation Training Improves Lumbar Puncture Skills

Clinical question: What effect does simulation have on lumbar puncture (LP) skills of PGY1 internal-medicine (IM) residents compared with PGY2-4 neurology residents who have not received simulation training?

Background: LPs are common procedures. The American College of General Medical Education does not define competency; neither do the internal-medicine (IM) or neurology board certifications. Simulation can improve skills in many areas but has not been well studied in LPs.

Study design: Pre-test-post-test.

Setting: Northwestern University’s Feinberg School of Medicine in Chicago.

Synopsis: The intervention group included 58 PGY1 IM residents, while the control group was 49 PGY2-to-PGY4 neurology residents. The pre-test consisted of a 21-point checklist. IM residents watched a three-hour video, performed LPs on simulators, and received feedback. The post-test was a clinical skills examination using the checklist. If this exam was failed, the participant practiced and was retested. Neurology residents completed the pre-test and demonstrated an LP using the simulator.

Pre-test passing was achieved by only 2% of IM residents and 6% of neurology residents. Post-test passing was achieved by 95% of the IM residents on the first trial and 100% of IM residents after an hour of additional training. IM mean scores increased to 95.7% from 46.3%, while the mean score of neurology residents was 65.4%.

This study is limited by its single-center nature, as education is variable from center to center. The study evaluated the proficiency on simulators only, and it did not evaluate the proficiency of the participants on patients.

Bottom line: Simulation training improves lumbar puncture skills.

Citation: Barsuk JH, Cohen ER, Caprio T, McGaghie WC, Simuni T, Wayne DB. Simulation-based education with mastery learning improves residents’ lumbar puncture skills. Neurology. 2012;79(2):132-137.

Primary-Care Physicians Do Not Use Publicly Reported Data When Referring Patients to Hospitals

Clinical question: When referring patients with pneumonia to the hospital, what factors do primary-care physicians (PCPs) consider?

Background: Publicly reported data are widely available. Pneumonia has publicly reported quality measures and is a common reason for hospitalization. Fewer PCPs are attending in the hospital due to the hospitalist movement; therefore, PCPs refer patients to a hospital when the need arises.

Study design: Online survey.

Setting: PCPs within 10 miles of Springfield, Mass.

Synopsis: A total of 92 PCPs responded to the survey, which included presentation of a case regarding a patient with pneumonia. PCPs were asked the importance of multiple factors leading to their decision to refer to a hospital. Familiarity with the hospital (70%), patient preference (62%), and admitting arrangements with a hospitalist group (62%) were considered to be very important to the PCPs that responded to the survey. Publicly reported data were very important to only 18% of respondents, and zero reported using publicly reported data when referring patients.

Importance of specific quality measures also was queried; antibiotics given within six hours of arrival (66%), appropriate choice of antibiotics (63%), and blood cultures prior to antibiotic administration (51%) were very important to respondents. Prestige, such as magnet status and U.S. News and World Report “Best Hospital” status, were deemed important by about 40% of PCPs.

Bottom line: Despite the availability of publicly reported data, PCPs do not use this information to refer patients to the hospital.

Citation: Morsi E, Lindenauer PK, Rothberg MB. Primary care physicians’ use of publicly reported quality data in hospital referral decisions. J Hosp Med. 2012;7(5):370-375.

What Works for Medication Reconciliation?

Clinical question: What are the most effective practices for medication reconciliation in the hospital setting?

Background: Medication discrepancies are common, occurring in as many as 70% of patients at hospital admission or discharge. Up to a third of these discrepancies have potential to cause patient harm, including prolonged hospital stays, ED visits, hospital recidivism, and use of other healthcare resources. Medication reconciliation (“med rec”) is a strategy for reducing these errors, though previous literature has not systematically reviewed best practices for hospital-based med rec.

Study design: Systematic review of literature.

Setting: Controlled studies from the U.S., Canada, Australia, New Zealand, Northern Ireland, United Kingdom, Belgium, Denmark, the Netherlands, and Sweden.

Synopsis: Investigators identified 26 controlled studies using a systematic search of English-language articles on med rec during inpatient hospitalizations published between Jan. 1, 1966, and Oct. 31, 2010. Fifteen studies reported on pharmacist-related interventions; six reported on technology-specific interventions; and five reported on other types of interventions, including staff education and use of standardized med-rec tools.

Analysis of these studies revealed that all of these interventions successfully decreased medication discrepancies and potential adverse drug events, but there was inconsistent benefit with regard to adverse drug events and healthcare utilization compared with usual care. The literature was most supportive of pharmacist-related interventions, including but not limited to comprehensive medication history at admission, med rec at discharge, patient counseling, discharge communication with outpatient providers, and post-discharge communication with the patient and post-hospital providers.

Bottom line: Successful med rec requires multiple interventions at various transitions of care and involves a variety of medical professionals. Patient-targeted interventions, including pharmacists, have the potential to decrease errors and adverse events.

Citation: Mueller S, Sponsler K, Kripalani S, Schnipper J. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-1069.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Prediction tool for neurological outcomes after in-hospital cardiac arrest
2. Radiation exposure in integrated healthcare systems, 1996-2010
3. Postoperative troponin predicts 30-day mortality
4. Clinical prediction model of mortality in acute heart failure
5. Indwelling pleural catheter vs. talc pleurodesis via chest tube
6. Early surgery for high-risk, native-valve endocarditis patients
7. Risk factors after ED visit for syncope
8. Acute hyperglycemia in CAP patients
9. Hospital delirium associated with cognitive decline, institutionalization, and death
10. Seven-day ciprofloxacin effective against acute pyelonephritis
11. Advance directives in community patients with heart failure
12. Chlorhexidine bathing effective against CVC-associated bloodstream infections
13. Simulation training improves lumbar puncture skills
14. PCP referrals to hospitals and publicly reported data
15. Medication reconciliation best practices

Prediction Tool Validated for Prognosticating Favorable Neurological Outcome after In-Hospital Cardiac Arrest

Clinical question: Does the Cardiac Arrest Survival Post Resuscitation In-Hospital (CASPRI) score accurately predict favorable neurological outcomes?

Background: Previous cardiac arrest prediction models have been focused on survival to discharge without consideration of neurological status and have not been translated into valid bedside prognostication tools. Neurologic prognosis can assist patients, families, and physicians in decisions about continued goals of care post-arrest.

Study design: Retrospective cohort study.

Setting: Acute-care hospitals.

Synopsis: Using the Get with the Guidelines Resuscitation Registry, 551 hospitals identified 42,957 patients who were successfully resuscitated from an in-hospital cardiac arrest from January 2000 to October 2009. Researchers developed a simple prediction tool for favorable neurological outcomes (defined as “no” or “moderate” neurological disability) at discharge. The 11 predictors used to calculate the CASPRI score are age; time to defibrillation; pre-arrest neurological status; hospital location; duration of resuscitation; and pre-arrest comorbidities: mechanical ventilation, renal insufficiency, hepatic insufficiency, sepsis, malignancy,

and hypotension.

Rates of favorable neurological outcome were similar between derivation cohort (24.6%) and validation cohort (24.5%). The model had excellent discrimination with a C score of 0.80. Probability of favorable neurological survival ranged from 70.7% in the top decile of patients (CASPRI <10) and 2.8% in bottom decile (CASPRI ≥ 28).

This tool is not generalizable to patients with out-of-hospital arrest or undergoing therapeutic hypothermia.

Bottom line: CASPRI is a simple bedside tool validated to estimate probability of favorable neurological outcome after in-hospital cardiac arrest.

Citation: Chan PS, Spertus JA, Krumholz HA, et al. A validated prediction tool for initial survivors in in-hospital cardiac arrest. Arch Intern Med. 2012;172(12):947-953.

Increased Use of Radiologic Imaging and Associated Radiation Exposure in Integrated Healthcare Systems, 1996-2010

Clinical question: How much has imaging utilization and associated radiation exposure increased over 15 years in integrated healthcare systems independent of financial incentives in a fee-for-service system?

Background: Use of diagnostic imaging has increased significantly within fee-for-service healthcare models. The associated radiation exposure has increased the risk of radiation-induced malignancies. Little is known about the pattern of imaging use in integrated healthcare systems without the financial incentives seen in other models of care.

Study design: Retrospective cohort study.

Setting: Six integrated healthcare systems in the U.S.

Synopsis: The number of diagnostic imaging studies performed and estimated radiation exposure were determined from analysis of electronic medical records from member patients enrolled in health systems in the HMO Research Network from 1996 to 2010. Annual increases in use of advanced diagnostics were noted in CT (7.8% annual growth), MRI (10%), ultrasound (3.9%), and PET (57%) studies.

Increased CT use over the 15-year study period resulted in increased radiation exposure, doubling mean per capita effective dose (1.2 mSv to 2.3 mSv), as well as those receiving high exposure (1.2% to 2.5%) and very high exposure (0.6% to 1.4%).

The increased imaging use and radiation exposure among HMO enrollees was similar to that of fee-for-service Medicare patients in previous studies.

Bottom line: There is a significant increase in use of diagnostic imaging studies and associated radiation exposure among integrated healthcare system enrollees from 1996 to 2010, similar to patients in fee-for-service health plans.

Citation: Smith-Bindman R, Miglioretti DL, Johnson E, et al. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010. JAMA. 2012;307(22):2400-2409.

Postoperative Troponin Predicts 30-Day Mortality

Clinical question: Does postoperative peak troponin level predict 30-day mortality in patients undergoing noncardiac surgery?

Background: The use of postoperative peak troponin levels in predicting 30-day mortality for patients undergoing noncardiac surgery has not been studied extensively. Identifying patients at high risk for death following noncardiac surgery could facilitate appropriate postoperative care and improve survival.

Study design: Prospective cohort study.

Setting: International university and nonuniversity hospitals.

Synopsis: The Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study is a large, international, multicenter, prospective cohort study designed to evaluate the major complications of noncardiac surgery. More than 15,100 patients ages 45 and older requiring at least an overnight hospitalization were enrolled following noncardiac surgery.

Peak troponin measurements during the first three postoperative days of 0.01 ng/ml or less, 0.02 ng/ml, 0.03 ng/ml to 0.29 ng/ml, and 0.3 ng/ml or greater had 30-day mortality rates of 1.0%, 4.0%, 9.3%, and 16.9%, respectively.

This study demonstrates the sensitivity of troponin measurement for predicting postoperative 30-day mortality in patients undergoing noncardiac surgery. The study does not address interventions based on an increased postoperative troponin level. Future studies might investigate postoperative modifiable risk factors.

Bottom line: Postoperative peak troponin level predicts 30-day mortality in patients undergoing noncardiac surgery.

Citation: Devereaux PJ, Chan MT, Alonso-Coello P, et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA. 2012;307(21):2295-2304.

Clinical Prediction Model of Mortality in Acute Heart Failure

Clinical question: Can a clinical prediction model accurately risk-stratify patients presenting to the ED with acute heart failure?

Background: Accurately prognosticating mortality is essential when determining whether to hospitalize or discharge patients presenting to the ED with acute heart failure. Evidence-based clinical prediction models enable physicians to risk-stratify patients and optimize care.

Study design: Retrospective cohort study.

Setting: Multicenter study of 86 hospitals in Ontario, Canada.

Synopsis: Data collected from 12,591 patients who presented to EDs with acute heart failure in Ontario were analyzed. A clinical prediction model of seven-day mortality of discharged and hospitalized patients was derived and validated. The Emergency Heart Failure Mortality Risk Grade (EHMRG) found an increased mortality based on higher triage heart rate, lower triage systolic blood pressure, initial oxygen saturation, and elevated troponin levels. This model uses readily available data collected in ED visits. The high-risk EHMRG score predicted about 8% seven-day mortality versus 0.3% in the low-risk score.

This model was not applied to chronic heart failure, did not utilize left ventricular function, and does not differentiate between systolic and diastolic heart failure.

Bottom line: The Emergency Heart Failure Mortality Risk Grade predicts seven-day mortality in acute heart failure in the emergent setting.

Citation: Lee DS, Stitt A, Austin PC, et al. Prediction of heart failure mortality in emergent care: a cohort study. Ann Intern Med. 2012;156(11):767-775.

Indwelling Pleural Catheter Is as Effective as Talc Pleurodesis Via Chest Tube in Relieving Dyspnea in Patients with Malignant Pleural Effusion

Clinical question: Is indwelling pleural catheter (IPC) as effective as chest tube and talc pleurodesis (talc) in improving dyspnea from malignant pleural effusion in patients who had no previous pleurodesis?

Background: Despite guidelines recommending chest tube insertion with pleurodesis as a first-line treatment for symptom palliation from malignant pleural effusion, there has been no randomized trial comparing indwelling pleural catheter with chest tube and talc pleurodesis.

Study design: Open-label, randomized controlled trial.

Setting: Seven hospitals in the United Kingdom.

Synopsis: One hundred six patients with malignant pleural effusion were randomized to undergo either IPC or talc treatment, and their daily mean dyspnea was measured. There was a clinically significant improvement of dyspnea in both IPC and talc groups over the first 42 days of the trial, without any significant difference in dyspnea between the two groups. After six months, researchers found a clinically significant decrease in dyspnea in the IPC group compared with the talc group. Chest pain and global quality of life were improved and were similar in both groups throughout the trial period. Length of hospital stay was significantly shorter in the IPC group compared with the talc group, but more patients in the IPC group experienced adverse events.

Bottom line: Indwelling pleural catheter is as effective as talc pleurodesis in reliving dyspnea from malignant pleural effusion; however, IPC is associated with increased adverse events despite shorter length of hospital stay.

Citation: Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs. chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383-2389.

Early Surgery Better than Conventional Treatment in High-Risk Native-Valve Endocarditis

Clinical question: Is early cardiac surgery better than conventional treatment for patients with left-sided, native-valve, infective endocarditis?

Background: Although guidelines strongly recommend early surgery for patients with infective endocarditis and congestive heart failure, the timing of surgery for patients with large vegetations and high risk of embolism without heart failure symptoms remains controversial.

Study design: Prospective, randomized trial.

Setting: Two medical centers in South Korea.

Synopsis: Seventy-six patients with left-sided, native-valve, infective endocarditis with a high risk of embolism (defined as vegetation with a diameter greater than 10 mm or severe mitral or aortic valve disease) were randomized to undergo early surgery (within 48 hours of enrollment) or conventional treatment (antibiotic therapy and surgery only if complications required urgent surgery). The primary outcome of composite in-hospital death or

clinical embolic events within six weeks of the trial occurred in only one patient in the early surgery group, compared with nine patients in the conventional group (hazard ratio 0.10, 95% CI, 0.01-0.82, P=0.03).

There was no difference in all-cause mortality at six months between the two groups, but the rate of composite endpoint of death from any cause, embolic events, or recurrence of infective endocarditis at six months was significantly lower in the early surgery group compared with the conventional group.

Bottom line: Early cardiac surgery for patients with left-sided, native-valve infective endocarditis with a high risk of embolism significantly improved the composite outcome of all-cause mortality, embolic events, or recurrence of endocarditis compared with the conventional therapy.

Citation: Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med. 2012;366(26):2466-2473.

Risk Factors for Short-Term Mortality after Emergency Department Visit for Syncope

Clinical question: What are the risk factors for short-term mortality after an ED evaluation for syncope or near-syncope?

Background: Syncope accounts for 1% to 2% of all ED visits and an equal number of hospital admissions. The risk of death after an ED visit for syncope is poorly understood, resulting in frequent hospital admissions.

Study design: Retrospective cohort study.

Setting: EDs in Southern California.

Synopsis: Authors evaluated 23,951 ED visits resulting in syncope as sole primary diagnosis. Age was identified as the most significant risk factor for short-term mortality. Cumulative survival data revealed that more than 1% of patients 60 or older died by 30 days. There were 215 deaths (2.84%) in patients hospitalized from the ED and 66 deaths (0.45%) among patients not hospitalized.

Pre-existing comorbidities significantly associated with increased mortality included heart failure (HR=14.3 in ages 18-53; HR=3.09 in ages 60-79; HR=2.34 in ages 80-plus), diabetes (HR=1.49), seizure (HR=1.65), dementia (HR=1.41), and a recent prior visit for syncope (HR=1.86). The risk of death by 30 days was less than 0.2% in patients under 60 without heart failure and more than 2.5% in patients of all ages with heart failure.

Bottom line: After an ED visit for syncope, patients with a history of heart failure and patients 60 and older have a significantly increased risk of short-term mortality.

Citation: Derose SF, Gabayan GZ, Chiu VY, Sun BC. Patterns and preexisting risk factors of 30-day mortality after a primary discharge diagnosis of syncope or near syncope. Acad Emerg Med. 2012;19(5):488-496.

Acute Hyperglycemia Associated with Increased Mortality in Community-Acquired Pneumonia

Clinical question: In patients admitted to the hospital for community-acquired pneumonia, is serum glucose level on admission associated with mortality?

Background: Some retrospective studies have shown an association between alterations in serum glucose levels or pre-existing diabetes and higher mortality due to infections, while other studies have shown no clear association.

Study design: Multicenter, prospective cohort study.

Setting: Hospitals and private practices in Germany, Switzerland, and Austria.

Synopsis: Prospective data from 6,891 patients were included in the analysis. Patients without diabetes and normal serum glucose levels had the lowest mortality after 90 days. Patients without diabetes but with mild acute hyperglycemia (108 mg/dL to 198 mg/dL) had a significantly increased risk of death at 90 days (HR 1.56), and patients without diabetes but with more severe acute hyperglycemia (over 252 mg/dL) had an even higher risk of death at 90 days (HR 2.37).

The 90-day mortality rate was significantly higher in patients with pre-existing diabetes (HR 2.47), although this was not affected by serum glucose levels on admission.

Bottom line: Acute hyperglycemia, as well as pre-existing diabetes, was associated with an increased risk of 90-day mortality in patients with community acquired pneumonia.

Citation: Lepper PM, Ott S, Nüesch E, et al. Serum glucose levels for predicting death in patients admitted to hospital for community acquired pneumonia: prospective cohort study. BMJ. 2012;344:e3397.

Hospital Delirium Associated with Cognitive Decline, Institutionalization, and Death

Clinical question: What is the risk of subsequent cognitive decline, institutionalization, or death due to delirium in patients with dementia?

Background: Patients suffering delirium during hospitalization can suffer additional cognitive decline. Whether this is due to additional damage from the delirium state or reflects pre-existing cognitive vulnerability remains uncertain.

Study design: Prospective analysis of a cohort of Alzheimer’s patients.

Setting: Massachusetts community-based disease registry.

Synopsis: The analysis compared nonhospitalized individuals to patients hospitalized with, and without, delirium. In 771 individuals with dementia, at least one adverse outcome (including cognitive decline, institutionalization, or death) occurred in 32% of those not hospitalized, 55% of those hospitalized without delirium, and 79% of those hospitalized with delirium. Even after adjusting for confounders, hospitalization increased the risk for each of the adverse outcomes; the highest risk was in those with delirium.

Among hospitalized patients, the authors estimated 1 in 5 cases of cognitive decline, 1 in 7 institutionalizations, and 1 in 16 deaths were attributable to delirium. Some of the attributed risk could be the result of residual confounding from unmeasured variables, limiting conclusions of causality. Despite these limitations, this study supports the hypothesis that delirium prevention measures could improve important patient outcomes.

Bottom line: Hospitalization is associated with high rates of adverse outcomes in elderly patients with dementia, the worst of which occurs in those who experience delirium.

Citation: Fong TG, Jones RN, Marcantonio ER, et al. Adverse outcomes after hospitalization and delirium in persons with Alzheimer disease. Ann Int Med. 2012;156:848-856.

In Acute Pyelonephritis, a Seven-Day Course of Ciprofloxacin is Effective in Obtaining Clinical Cure

Clinical question: What is the efficacy of ciprofloxacin for seven days compared with 14 days in women with community-acquired acute pyelonephritis?

Background: Community-acquired acute pyelonephritis is a common and sometimes serious infection in women. In an era of increasing antibiotic resistance worldwide, it is prudent to reduce antibiotic utilization. There are limited controlled trials to assess the optimum duration of antibiotic treatment for this common infection.

Study design: Prospective, randomized, double-blind, noninferiority trial.

Setting: Twenty-one infectious-disease centers in Sweden.

Synopsis: Researchers randomly assigned 284 women 18 or older with a presumptive diagnosis of acute pyelonephritis to ciprofloxacin treatment for seven or 14 days. The primary endpoint was clinical and bacteriological cure 10 to 14 days after the completion of the treatment regimen. Short-term clinical cure occurred in 97% of the patients treated for seven days and 96% treated for 14 days. Long-term follow-up showed cumulative efficacy of 93% in each group. Both regimens were well tolerated.

Patients in this study had a low occurrence of complicated (9%) and recurrent (13%) infections. Whether short courses of antibiotics are effective in more complicated infections cannot be ascertained from this study. Also, the high cure rate obtained with a seven-day course of ciprofloxacin should not be extrapolated to other classes of antibiotics. Fluoroquinolones, such as ciprofloxacin, are recommended as first-line agents for empiric oral treatment of acute pyelonephritis if the resistance rate of the uropathogens remains lower than 10%; however, there is growing evidence that E. coli strains are becoming increasingly resistant to ciprofloxacin, limiting its usefulness.

Bottom line: Acute pyelonephritis in women can be treated successfully and safely with a seven-day course of ciprofloxacin, in areas with low ciprofloxacin resistance.

Citation: Sandberg T, Skoog G, Hermansson AB, et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomized, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet. 2012;380:484-490.

Advance Directives in Community Patients with Heart Failure

Clinical question: How prevalent are advance directives in heart-failure patients, and does a completed advance directive decrease end-of-life resource use (hospitalizations, ICU admissions, mechanical ventilation)?

Background: Heart failure is a common chronic and fatal disease. End-of-life care in heart-failure patients is associated with extremely high healthcare utilization. Heart failure guidelines recommend completing advance directives in all patients.

Study design: Population-based longitudinal cohort study.

Setting: Rochester Epidemiology Project in Olmstead County, Minn.

Synopsis: Investigators enrolled 608 patients presenting with heart failure between October 2007 and October 2011. At the time of enrollment, only 41% of the patients had existing advance directives. Independent predictors of advance directive completion included older age, history of malignancy, and renal dysfunction.

After a mean follow-up of 1.8 years, 164 patients (27%) had died. Among those patients, 106 had an advance directive (64.6%) at time of death—75 had an advance directive at the time of enrollment and another 31 completed an advance directive after enrollment.

Twenty-five patients (23.6%) specified DNR/DNI and another 39 (36.8%) denoted limitations on aggressiveness of care if death was imminent. Among the patients who died, 88 (53.7%) were hospitalized in the last month of their life and 50 (30.5%) died in the hospital. There was no difference in hospitalizations between those with an advance directive specifying limits and those who did not specify limits (OR 1.26, 95% CI 0.64-2.48). However, those with an advance directive specifying limits were less frequently mechanically ventilated (OR 0.26, 95% CI 0.06-0.88), and there was a trend toward them being less frequently admitted into the ICU (OR 0.45, 95% CI 0.16-1.29).

Bottom line: Less than half of community patients with heart failure had an advance directive, and many of these failed to address end-of-life decisions. Patients with an advance directive that specified limits in care were less likely to receive mechanical ventilation.

Citation: Dunlay SM, Swetz KM, Mueller PS, Roger VL. Advance directives in community patients with heart failure. Circ Cardiovasc Qual Outcomes. 2012;5:283-289.

Chlorhexidine Bathing Associated with Significant, Sustainable Reductions in Central-Venous-Catheter-Associated Bloodstream Infection

Clinical question: What is the impact, and sustainability, of chlorhexidine bathing on central-venous-catheter-associated bloodstream infections?

Background: Chlorhexidine bathing has been associated with reductions in healthcare-associated bloodstream infections, including vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus. No prospective studies have evaluated the impact and sustainability of chlorhexidine bathing.

Study design: Prospective, three-phase study.

Setting: Medical-surgical ICUs and respiratory-care units at five New York hospitals.

Synopsis: In the pre-intervention phase (six to nine months, 1,808 admissions), patients were bathed with soap and water or nonmedicated bathing cloths. In the intervention phase (eight months, 1,832 admissions), patients were bathed with 2% chlorhexidine cloths. In the post-intervention phase (12 months, 2,834 admissions), chlorhexidine bathing was continued without oversight by researchers.

During the intervention phase, there were significantly fewer central-venous-catheter-associated bloodstream infections (2.6/1,000 catheter days vs. 6.4/1,000 pre-intervention). The reductions in bloodstream infections were sustained during the post-intervention period (2.9/1,000 catheter days). Compliance with chlorhexidine bathing was 82% and 88% during the intervention and post-intervention phases, and was well tolerated by the patients.

Limitations of this study include lack of patient-specific data and severity of illness data, as well as lack of randomization and blinding. Although not evaluated in this study, the savings associated with decreased bloodstream infections likely outweigh the cost of chlorhexidine bathing.

Bottom line: Chlorhexidine bathing is a well-tolerated, sustainable intervention that significantly reduces central-venous-catheter-associated bloodstream infections.

Citation: Montecalvo MA, McKenna D, Yarrish R, et al. Chlorhexidine bathing to reduce central venous catheter-associated bloodstream infection: impact and sustainability. Am J Med. 2012;125(5):505-511.

Simulation Training Improves Lumbar Puncture Skills

Clinical question: What effect does simulation have on lumbar puncture (LP) skills of PGY1 internal-medicine (IM) residents compared with PGY2-4 neurology residents who have not received simulation training?

Background: LPs are common procedures. The American College of General Medical Education does not define competency; neither do the internal-medicine (IM) or neurology board certifications. Simulation can improve skills in many areas but has not been well studied in LPs.

Study design: Pre-test-post-test.

Setting: Northwestern University’s Feinberg School of Medicine in Chicago.

Synopsis: The intervention group included 58 PGY1 IM residents, while the control group was 49 PGY2-to-PGY4 neurology residents. The pre-test consisted of a 21-point checklist. IM residents watched a three-hour video, performed LPs on simulators, and received feedback. The post-test was a clinical skills examination using the checklist. If this exam was failed, the participant practiced and was retested. Neurology residents completed the pre-test and demonstrated an LP using the simulator.

Pre-test passing was achieved by only 2% of IM residents and 6% of neurology residents. Post-test passing was achieved by 95% of the IM residents on the first trial and 100% of IM residents after an hour of additional training. IM mean scores increased to 95.7% from 46.3%, while the mean score of neurology residents was 65.4%.

This study is limited by its single-center nature, as education is variable from center to center. The study evaluated the proficiency on simulators only, and it did not evaluate the proficiency of the participants on patients.

Bottom line: Simulation training improves lumbar puncture skills.

Citation: Barsuk JH, Cohen ER, Caprio T, McGaghie WC, Simuni T, Wayne DB. Simulation-based education with mastery learning improves residents’ lumbar puncture skills. Neurology. 2012;79(2):132-137.

Primary-Care Physicians Do Not Use Publicly Reported Data When Referring Patients to Hospitals

Clinical question: When referring patients with pneumonia to the hospital, what factors do primary-care physicians (PCPs) consider?

Background: Publicly reported data are widely available. Pneumonia has publicly reported quality measures and is a common reason for hospitalization. Fewer PCPs are attending in the hospital due to the hospitalist movement; therefore, PCPs refer patients to a hospital when the need arises.

Study design: Online survey.

Setting: PCPs within 10 miles of Springfield, Mass.

Synopsis: A total of 92 PCPs responded to the survey, which included presentation of a case regarding a patient with pneumonia. PCPs were asked the importance of multiple factors leading to their decision to refer to a hospital. Familiarity with the hospital (70%), patient preference (62%), and admitting arrangements with a hospitalist group (62%) were considered to be very important to the PCPs that responded to the survey. Publicly reported data were very important to only 18% of respondents, and zero reported using publicly reported data when referring patients.

Importance of specific quality measures also was queried; antibiotics given within six hours of arrival (66%), appropriate choice of antibiotics (63%), and blood cultures prior to antibiotic administration (51%) were very important to respondents. Prestige, such as magnet status and U.S. News and World Report “Best Hospital” status, were deemed important by about 40% of PCPs.

Bottom line: Despite the availability of publicly reported data, PCPs do not use this information to refer patients to the hospital.

Citation: Morsi E, Lindenauer PK, Rothberg MB. Primary care physicians’ use of publicly reported quality data in hospital referral decisions. J Hosp Med. 2012;7(5):370-375.

What Works for Medication Reconciliation?

Clinical question: What are the most effective practices for medication reconciliation in the hospital setting?

Background: Medication discrepancies are common, occurring in as many as 70% of patients at hospital admission or discharge. Up to a third of these discrepancies have potential to cause patient harm, including prolonged hospital stays, ED visits, hospital recidivism, and use of other healthcare resources. Medication reconciliation (“med rec”) is a strategy for reducing these errors, though previous literature has not systematically reviewed best practices for hospital-based med rec.

Study design: Systematic review of literature.

Setting: Controlled studies from the U.S., Canada, Australia, New Zealand, Northern Ireland, United Kingdom, Belgium, Denmark, the Netherlands, and Sweden.

Synopsis: Investigators identified 26 controlled studies using a systematic search of English-language articles on med rec during inpatient hospitalizations published between Jan. 1, 1966, and Oct. 31, 2010. Fifteen studies reported on pharmacist-related interventions; six reported on technology-specific interventions; and five reported on other types of interventions, including staff education and use of standardized med-rec tools.

Analysis of these studies revealed that all of these interventions successfully decreased medication discrepancies and potential adverse drug events, but there was inconsistent benefit with regard to adverse drug events and healthcare utilization compared with usual care. The literature was most supportive of pharmacist-related interventions, including but not limited to comprehensive medication history at admission, med rec at discharge, patient counseling, discharge communication with outpatient providers, and post-discharge communication with the patient and post-hospital providers.

Bottom line: Successful med rec requires multiple interventions at various transitions of care and involves a variety of medical professionals. Patient-targeted interventions, including pharmacists, have the potential to decrease errors and adverse events.

Citation: Mueller S, Sponsler K, Kripalani S, Schnipper J. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-1069.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Prediction tool for neurological outcomes after in-hospital cardiac arrest
2. Radiation exposure in integrated healthcare systems, 1996-2010
3. Postoperative troponin predicts 30-day mortality
4. Clinical prediction model of mortality in acute heart failure
5. Indwelling pleural catheter vs. talc pleurodesis via chest tube
6. Early surgery for high-risk, native-valve endocarditis patients
7. Risk factors after ED visit for syncope
8. Acute hyperglycemia in CAP patients
9. Hospital delirium associated with cognitive decline, institutionalization, and death
10. Seven-day ciprofloxacin effective against acute pyelonephritis
11. Advance directives in community patients with heart failure
12. Chlorhexidine bathing effective against CVC-associated bloodstream infections
13. Simulation training improves lumbar puncture skills
14. PCP referrals to hospitals and publicly reported data
15. Medication reconciliation best practices

Prediction Tool Validated for Prognosticating Favorable Neurological Outcome after In-Hospital Cardiac Arrest

Clinical question: Does the Cardiac Arrest Survival Post Resuscitation In-Hospital (CASPRI) score accurately predict favorable neurological outcomes?

Background: Previous cardiac arrest prediction models have been focused on survival to discharge without consideration of neurological status and have not been translated into valid bedside prognostication tools. Neurologic prognosis can assist patients, families, and physicians in decisions about continued goals of care post-arrest.

Study design: Retrospective cohort study.

Setting: Acute-care hospitals.

Synopsis: Using the Get with the Guidelines Resuscitation Registry, 551 hospitals identified 42,957 patients who were successfully resuscitated from an in-hospital cardiac arrest from January 2000 to October 2009. Researchers developed a simple prediction tool for favorable neurological outcomes (defined as “no” or “moderate” neurological disability) at discharge. The 11 predictors used to calculate the CASPRI score are age; time to defibrillation; pre-arrest neurological status; hospital location; duration of resuscitation; and pre-arrest comorbidities: mechanical ventilation, renal insufficiency, hepatic insufficiency, sepsis, malignancy,

and hypotension.

Rates of favorable neurological outcome were similar between derivation cohort (24.6%) and validation cohort (24.5%). The model had excellent discrimination with a C score of 0.80. Probability of favorable neurological survival ranged from 70.7% in the top decile of patients (CASPRI <10) and 2.8% in bottom decile (CASPRI ≥ 28).

This tool is not generalizable to patients with out-of-hospital arrest or undergoing therapeutic hypothermia.

Bottom line: CASPRI is a simple bedside tool validated to estimate probability of favorable neurological outcome after in-hospital cardiac arrest.

Citation: Chan PS, Spertus JA, Krumholz HA, et al. A validated prediction tool for initial survivors in in-hospital cardiac arrest. Arch Intern Med. 2012;172(12):947-953.

Increased Use of Radiologic Imaging and Associated Radiation Exposure in Integrated Healthcare Systems, 1996-2010

Clinical question: How much has imaging utilization and associated radiation exposure increased over 15 years in integrated healthcare systems independent of financial incentives in a fee-for-service system?

Background: Use of diagnostic imaging has increased significantly within fee-for-service healthcare models. The associated radiation exposure has increased the risk of radiation-induced malignancies. Little is known about the pattern of imaging use in integrated healthcare systems without the financial incentives seen in other models of care.

Study design: Retrospective cohort study.

Setting: Six integrated healthcare systems in the U.S.

Synopsis: The number of diagnostic imaging studies performed and estimated radiation exposure were determined from analysis of electronic medical records from member patients enrolled in health systems in the HMO Research Network from 1996 to 2010. Annual increases in use of advanced diagnostics were noted in CT (7.8% annual growth), MRI (10%), ultrasound (3.9%), and PET (57%) studies.

Increased CT use over the 15-year study period resulted in increased radiation exposure, doubling mean per capita effective dose (1.2 mSv to 2.3 mSv), as well as those receiving high exposure (1.2% to 2.5%) and very high exposure (0.6% to 1.4%).

The increased imaging use and radiation exposure among HMO enrollees was similar to that of fee-for-service Medicare patients in previous studies.

Bottom line: There is a significant increase in use of diagnostic imaging studies and associated radiation exposure among integrated healthcare system enrollees from 1996 to 2010, similar to patients in fee-for-service health plans.

Citation: Smith-Bindman R, Miglioretti DL, Johnson E, et al. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010. JAMA. 2012;307(22):2400-2409.

Postoperative Troponin Predicts 30-Day Mortality

Clinical question: Does postoperative peak troponin level predict 30-day mortality in patients undergoing noncardiac surgery?

Background: The use of postoperative peak troponin levels in predicting 30-day mortality for patients undergoing noncardiac surgery has not been studied extensively. Identifying patients at high risk for death following noncardiac surgery could facilitate appropriate postoperative care and improve survival.

Study design: Prospective cohort study.

Setting: International university and nonuniversity hospitals.

Synopsis: The Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study is a large, international, multicenter, prospective cohort study designed to evaluate the major complications of noncardiac surgery. More than 15,100 patients ages 45 and older requiring at least an overnight hospitalization were enrolled following noncardiac surgery.

Peak troponin measurements during the first three postoperative days of 0.01 ng/ml or less, 0.02 ng/ml, 0.03 ng/ml to 0.29 ng/ml, and 0.3 ng/ml or greater had 30-day mortality rates of 1.0%, 4.0%, 9.3%, and 16.9%, respectively.

This study demonstrates the sensitivity of troponin measurement for predicting postoperative 30-day mortality in patients undergoing noncardiac surgery. The study does not address interventions based on an increased postoperative troponin level. Future studies might investigate postoperative modifiable risk factors.

Bottom line: Postoperative peak troponin level predicts 30-day mortality in patients undergoing noncardiac surgery.

Citation: Devereaux PJ, Chan MT, Alonso-Coello P, et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA. 2012;307(21):2295-2304.

Clinical Prediction Model of Mortality in Acute Heart Failure

Clinical question: Can a clinical prediction model accurately risk-stratify patients presenting to the ED with acute heart failure?

Background: Accurately prognosticating mortality is essential when determining whether to hospitalize or discharge patients presenting to the ED with acute heart failure. Evidence-based clinical prediction models enable physicians to risk-stratify patients and optimize care.

Study design: Retrospective cohort study.

Setting: Multicenter study of 86 hospitals in Ontario, Canada.

Synopsis: Data collected from 12,591 patients who presented to EDs with acute heart failure in Ontario were analyzed. A clinical prediction model of seven-day mortality of discharged and hospitalized patients was derived and validated. The Emergency Heart Failure Mortality Risk Grade (EHMRG) found an increased mortality based on higher triage heart rate, lower triage systolic blood pressure, initial oxygen saturation, and elevated troponin levels. This model uses readily available data collected in ED visits. The high-risk EHMRG score predicted about 8% seven-day mortality versus 0.3% in the low-risk score.

This model was not applied to chronic heart failure, did not utilize left ventricular function, and does not differentiate between systolic and diastolic heart failure.

Bottom line: The Emergency Heart Failure Mortality Risk Grade predicts seven-day mortality in acute heart failure in the emergent setting.

Citation: Lee DS, Stitt A, Austin PC, et al. Prediction of heart failure mortality in emergent care: a cohort study. Ann Intern Med. 2012;156(11):767-775.

Indwelling Pleural Catheter Is as Effective as Talc Pleurodesis Via Chest Tube in Relieving Dyspnea in Patients with Malignant Pleural Effusion

Clinical question: Is indwelling pleural catheter (IPC) as effective as chest tube and talc pleurodesis (talc) in improving dyspnea from malignant pleural effusion in patients who had no previous pleurodesis?

Background: Despite guidelines recommending chest tube insertion with pleurodesis as a first-line treatment for symptom palliation from malignant pleural effusion, there has been no randomized trial comparing indwelling pleural catheter with chest tube and talc pleurodesis.

Study design: Open-label, randomized controlled trial.

Setting: Seven hospitals in the United Kingdom.

Synopsis: One hundred six patients with malignant pleural effusion were randomized to undergo either IPC or talc treatment, and their daily mean dyspnea was measured. There was a clinically significant improvement of dyspnea in both IPC and talc groups over the first 42 days of the trial, without any significant difference in dyspnea between the two groups. After six months, researchers found a clinically significant decrease in dyspnea in the IPC group compared with the talc group. Chest pain and global quality of life were improved and were similar in both groups throughout the trial period. Length of hospital stay was significantly shorter in the IPC group compared with the talc group, but more patients in the IPC group experienced adverse events.

Bottom line: Indwelling pleural catheter is as effective as talc pleurodesis in reliving dyspnea from malignant pleural effusion; however, IPC is associated with increased adverse events despite shorter length of hospital stay.

Citation: Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs. chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383-2389.

Early Surgery Better than Conventional Treatment in High-Risk Native-Valve Endocarditis

Clinical question: Is early cardiac surgery better than conventional treatment for patients with left-sided, native-valve, infective endocarditis?

Background: Although guidelines strongly recommend early surgery for patients with infective endocarditis and congestive heart failure, the timing of surgery for patients with large vegetations and high risk of embolism without heart failure symptoms remains controversial.

Study design: Prospective, randomized trial.

Setting: Two medical centers in South Korea.

Synopsis: Seventy-six patients with left-sided, native-valve, infective endocarditis with a high risk of embolism (defined as vegetation with a diameter greater than 10 mm or severe mitral or aortic valve disease) were randomized to undergo early surgery (within 48 hours of enrollment) or conventional treatment (antibiotic therapy and surgery only if complications required urgent surgery). The primary outcome of composite in-hospital death or

clinical embolic events within six weeks of the trial occurred in only one patient in the early surgery group, compared with nine patients in the conventional group (hazard ratio 0.10, 95% CI, 0.01-0.82, P=0.03).

There was no difference in all-cause mortality at six months between the two groups, but the rate of composite endpoint of death from any cause, embolic events, or recurrence of infective endocarditis at six months was significantly lower in the early surgery group compared with the conventional group.

Bottom line: Early cardiac surgery for patients with left-sided, native-valve infective endocarditis with a high risk of embolism significantly improved the composite outcome of all-cause mortality, embolic events, or recurrence of endocarditis compared with the conventional therapy.

Citation: Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med. 2012;366(26):2466-2473.

Risk Factors for Short-Term Mortality after Emergency Department Visit for Syncope

Clinical question: What are the risk factors for short-term mortality after an ED evaluation for syncope or near-syncope?

Background: Syncope accounts for 1% to 2% of all ED visits and an equal number of hospital admissions. The risk of death after an ED visit for syncope is poorly understood, resulting in frequent hospital admissions.

Study design: Retrospective cohort study.

Setting: EDs in Southern California.

Synopsis: Authors evaluated 23,951 ED visits resulting in syncope as sole primary diagnosis. Age was identified as the most significant risk factor for short-term mortality. Cumulative survival data revealed that more than 1% of patients 60 or older died by 30 days. There were 215 deaths (2.84%) in patients hospitalized from the ED and 66 deaths (0.45%) among patients not hospitalized.

Pre-existing comorbidities significantly associated with increased mortality included heart failure (HR=14.3 in ages 18-53; HR=3.09 in ages 60-79; HR=2.34 in ages 80-plus), diabetes (HR=1.49), seizure (HR=1.65), dementia (HR=1.41), and a recent prior visit for syncope (HR=1.86). The risk of death by 30 days was less than 0.2% in patients under 60 without heart failure and more than 2.5% in patients of all ages with heart failure.

Bottom line: After an ED visit for syncope, patients with a history of heart failure and patients 60 and older have a significantly increased risk of short-term mortality.

Citation: Derose SF, Gabayan GZ, Chiu VY, Sun BC. Patterns and preexisting risk factors of 30-day mortality after a primary discharge diagnosis of syncope or near syncope. Acad Emerg Med. 2012;19(5):488-496.

Acute Hyperglycemia Associated with Increased Mortality in Community-Acquired Pneumonia

Clinical question: In patients admitted to the hospital for community-acquired pneumonia, is serum glucose level on admission associated with mortality?

Background: Some retrospective studies have shown an association between alterations in serum glucose levels or pre-existing diabetes and higher mortality due to infections, while other studies have shown no clear association.

Study design: Multicenter, prospective cohort study.

Setting: Hospitals and private practices in Germany, Switzerland, and Austria.

Synopsis: Prospective data from 6,891 patients were included in the analysis. Patients without diabetes and normal serum glucose levels had the lowest mortality after 90 days. Patients without diabetes but with mild acute hyperglycemia (108 mg/dL to 198 mg/dL) had a significantly increased risk of death at 90 days (HR 1.56), and patients without diabetes but with more severe acute hyperglycemia (over 252 mg/dL) had an even higher risk of death at 90 days (HR 2.37).

The 90-day mortality rate was significantly higher in patients with pre-existing diabetes (HR 2.47), although this was not affected by serum glucose levels on admission.

Bottom line: Acute hyperglycemia, as well as pre-existing diabetes, was associated with an increased risk of 90-day mortality in patients with community acquired pneumonia.

Citation: Lepper PM, Ott S, Nüesch E, et al. Serum glucose levels for predicting death in patients admitted to hospital for community acquired pneumonia: prospective cohort study. BMJ. 2012;344:e3397.

Hospital Delirium Associated with Cognitive Decline, Institutionalization, and Death

Clinical question: What is the risk of subsequent cognitive decline, institutionalization, or death due to delirium in patients with dementia?

Background: Patients suffering delirium during hospitalization can suffer additional cognitive decline. Whether this is due to additional damage from the delirium state or reflects pre-existing cognitive vulnerability remains uncertain.

Study design: Prospective analysis of a cohort of Alzheimer’s patients.

Setting: Massachusetts community-based disease registry.

Synopsis: The analysis compared nonhospitalized individuals to patients hospitalized with, and without, delirium. In 771 individuals with dementia, at least one adverse outcome (including cognitive decline, institutionalization, or death) occurred in 32% of those not hospitalized, 55% of those hospitalized without delirium, and 79% of those hospitalized with delirium. Even after adjusting for confounders, hospitalization increased the risk for each of the adverse outcomes; the highest risk was in those with delirium.

Among hospitalized patients, the authors estimated 1 in 5 cases of cognitive decline, 1 in 7 institutionalizations, and 1 in 16 deaths were attributable to delirium. Some of the attributed risk could be the result of residual confounding from unmeasured variables, limiting conclusions of causality. Despite these limitations, this study supports the hypothesis that delirium prevention measures could improve important patient outcomes.

Bottom line: Hospitalization is associated with high rates of adverse outcomes in elderly patients with dementia, the worst of which occurs in those who experience delirium.

Citation: Fong TG, Jones RN, Marcantonio ER, et al. Adverse outcomes after hospitalization and delirium in persons with Alzheimer disease. Ann Int Med. 2012;156:848-856.

In Acute Pyelonephritis, a Seven-Day Course of Ciprofloxacin is Effective in Obtaining Clinical Cure

Clinical question: What is the efficacy of ciprofloxacin for seven days compared with 14 days in women with community-acquired acute pyelonephritis?

Background: Community-acquired acute pyelonephritis is a common and sometimes serious infection in women. In an era of increasing antibiotic resistance worldwide, it is prudent to reduce antibiotic utilization. There are limited controlled trials to assess the optimum duration of antibiotic treatment for this common infection.

Study design: Prospective, randomized, double-blind, noninferiority trial.

Setting: Twenty-one infectious-disease centers in Sweden.

Synopsis: Researchers randomly assigned 284 women 18 or older with a presumptive diagnosis of acute pyelonephritis to ciprofloxacin treatment for seven or 14 days. The primary endpoint was clinical and bacteriological cure 10 to 14 days after the completion of the treatment regimen. Short-term clinical cure occurred in 97% of the patients treated for seven days and 96% treated for 14 days. Long-term follow-up showed cumulative efficacy of 93% in each group. Both regimens were well tolerated.

Patients in this study had a low occurrence of complicated (9%) and recurrent (13%) infections. Whether short courses of antibiotics are effective in more complicated infections cannot be ascertained from this study. Also, the high cure rate obtained with a seven-day course of ciprofloxacin should not be extrapolated to other classes of antibiotics. Fluoroquinolones, such as ciprofloxacin, are recommended as first-line agents for empiric oral treatment of acute pyelonephritis if the resistance rate of the uropathogens remains lower than 10%; however, there is growing evidence that E. coli strains are becoming increasingly resistant to ciprofloxacin, limiting its usefulness.

Bottom line: Acute pyelonephritis in women can be treated successfully and safely with a seven-day course of ciprofloxacin, in areas with low ciprofloxacin resistance.

Citation: Sandberg T, Skoog G, Hermansson AB, et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomized, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet. 2012;380:484-490.

Advance Directives in Community Patients with Heart Failure

Clinical question: How prevalent are advance directives in heart-failure patients, and does a completed advance directive decrease end-of-life resource use (hospitalizations, ICU admissions, mechanical ventilation)?

Background: Heart failure is a common chronic and fatal disease. End-of-life care in heart-failure patients is associated with extremely high healthcare utilization. Heart failure guidelines recommend completing advance directives in all patients.

Study design: Population-based longitudinal cohort study.

Setting: Rochester Epidemiology Project in Olmstead County, Minn.

Synopsis: Investigators enrolled 608 patients presenting with heart failure between October 2007 and October 2011. At the time of enrollment, only 41% of the patients had existing advance directives. Independent predictors of advance directive completion included older age, history of malignancy, and renal dysfunction.

After a mean follow-up of 1.8 years, 164 patients (27%) had died. Among those patients, 106 had an advance directive (64.6%) at time of death—75 had an advance directive at the time of enrollment and another 31 completed an advance directive after enrollment.

Twenty-five patients (23.6%) specified DNR/DNI and another 39 (36.8%) denoted limitations on aggressiveness of care if death was imminent. Among the patients who died, 88 (53.7%) were hospitalized in the last month of their life and 50 (30.5%) died in the hospital. There was no difference in hospitalizations between those with an advance directive specifying limits and those who did not specify limits (OR 1.26, 95% CI 0.64-2.48). However, those with an advance directive specifying limits were less frequently mechanically ventilated (OR 0.26, 95% CI 0.06-0.88), and there was a trend toward them being less frequently admitted into the ICU (OR 0.45, 95% CI 0.16-1.29).

Bottom line: Less than half of community patients with heart failure had an advance directive, and many of these failed to address end-of-life decisions. Patients with an advance directive that specified limits in care were less likely to receive mechanical ventilation.

Citation: Dunlay SM, Swetz KM, Mueller PS, Roger VL. Advance directives in community patients with heart failure. Circ Cardiovasc Qual Outcomes. 2012;5:283-289.

Chlorhexidine Bathing Associated with Significant, Sustainable Reductions in Central-Venous-Catheter-Associated Bloodstream Infection

Clinical question: What is the impact, and sustainability, of chlorhexidine bathing on central-venous-catheter-associated bloodstream infections?

Background: Chlorhexidine bathing has been associated with reductions in healthcare-associated bloodstream infections, including vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus. No prospective studies have evaluated the impact and sustainability of chlorhexidine bathing.

Study design: Prospective, three-phase study.

Setting: Medical-surgical ICUs and respiratory-care units at five New York hospitals.

Synopsis: In the pre-intervention phase (six to nine months, 1,808 admissions), patients were bathed with soap and water or nonmedicated bathing cloths. In the intervention phase (eight months, 1,832 admissions), patients were bathed with 2% chlorhexidine cloths. In the post-intervention phase (12 months, 2,834 admissions), chlorhexidine bathing was continued without oversight by researchers.

During the intervention phase, there were significantly fewer central-venous-catheter-associated bloodstream infections (2.6/1,000 catheter days vs. 6.4/1,000 pre-intervention). The reductions in bloodstream infections were sustained during the post-intervention period (2.9/1,000 catheter days). Compliance with chlorhexidine bathing was 82% and 88% during the intervention and post-intervention phases, and was well tolerated by the patients.

Limitations of this study include lack of patient-specific data and severity of illness data, as well as lack of randomization and blinding. Although not evaluated in this study, the savings associated with decreased bloodstream infections likely outweigh the cost of chlorhexidine bathing.

Bottom line: Chlorhexidine bathing is a well-tolerated, sustainable intervention that significantly reduces central-venous-catheter-associated bloodstream infections.

Citation: Montecalvo MA, McKenna D, Yarrish R, et al. Chlorhexidine bathing to reduce central venous catheter-associated bloodstream infection: impact and sustainability. Am J Med. 2012;125(5):505-511.

Simulation Training Improves Lumbar Puncture Skills

Clinical question: What effect does simulation have on lumbar puncture (LP) skills of PGY1 internal-medicine (IM) residents compared with PGY2-4 neurology residents who have not received simulation training?

Background: LPs are common procedures. The American College of General Medical Education does not define competency; neither do the internal-medicine (IM) or neurology board certifications. Simulation can improve skills in many areas but has not been well studied in LPs.

Study design: Pre-test-post-test.

Setting: Northwestern University’s Feinberg School of Medicine in Chicago.

Synopsis: The intervention group included 58 PGY1 IM residents, while the control group was 49 PGY2-to-PGY4 neurology residents. The pre-test consisted of a 21-point checklist. IM residents watched a three-hour video, performed LPs on simulators, and received feedback. The post-test was a clinical skills examination using the checklist. If this exam was failed, the participant practiced and was retested. Neurology residents completed the pre-test and demonstrated an LP using the simulator.

Pre-test passing was achieved by only 2% of IM residents and 6% of neurology residents. Post-test passing was achieved by 95% of the IM residents on the first trial and 100% of IM residents after an hour of additional training. IM mean scores increased to 95.7% from 46.3%, while the mean score of neurology residents was 65.4%.

This study is limited by its single-center nature, as education is variable from center to center. The study evaluated the proficiency on simulators only, and it did not evaluate the proficiency of the participants on patients.

Bottom line: Simulation training improves lumbar puncture skills.

Citation: Barsuk JH, Cohen ER, Caprio T, McGaghie WC, Simuni T, Wayne DB. Simulation-based education with mastery learning improves residents’ lumbar puncture skills. Neurology. 2012;79(2):132-137.

Primary-Care Physicians Do Not Use Publicly Reported Data When Referring Patients to Hospitals

Clinical question: When referring patients with pneumonia to the hospital, what factors do primary-care physicians (PCPs) consider?

Background: Publicly reported data are widely available. Pneumonia has publicly reported quality measures and is a common reason for hospitalization. Fewer PCPs are attending in the hospital due to the hospitalist movement; therefore, PCPs refer patients to a hospital when the need arises.

Study design: Online survey.

Setting: PCPs within 10 miles of Springfield, Mass.

Synopsis: A total of 92 PCPs responded to the survey, which included presentation of a case regarding a patient with pneumonia. PCPs were asked the importance of multiple factors leading to their decision to refer to a hospital. Familiarity with the hospital (70%), patient preference (62%), and admitting arrangements with a hospitalist group (62%) were considered to be very important to the PCPs that responded to the survey. Publicly reported data were very important to only 18% of respondents, and zero reported using publicly reported data when referring patients.

Importance of specific quality measures also was queried; antibiotics given within six hours of arrival (66%), appropriate choice of antibiotics (63%), and blood cultures prior to antibiotic administration (51%) were very important to respondents. Prestige, such as magnet status and U.S. News and World Report “Best Hospital” status, were deemed important by about 40% of PCPs.

Bottom line: Despite the availability of publicly reported data, PCPs do not use this information to refer patients to the hospital.

Citation: Morsi E, Lindenauer PK, Rothberg MB. Primary care physicians’ use of publicly reported quality data in hospital referral decisions. J Hosp Med. 2012;7(5):370-375.

What Works for Medication Reconciliation?

Clinical question: What are the most effective practices for medication reconciliation in the hospital setting?

Background: Medication discrepancies are common, occurring in as many as 70% of patients at hospital admission or discharge. Up to a third of these discrepancies have potential to cause patient harm, including prolonged hospital stays, ED visits, hospital recidivism, and use of other healthcare resources. Medication reconciliation (“med rec”) is a strategy for reducing these errors, though previous literature has not systematically reviewed best practices for hospital-based med rec.

Study design: Systematic review of literature.

Setting: Controlled studies from the U.S., Canada, Australia, New Zealand, Northern Ireland, United Kingdom, Belgium, Denmark, the Netherlands, and Sweden.

Synopsis: Investigators identified 26 controlled studies using a systematic search of English-language articles on med rec during inpatient hospitalizations published between Jan. 1, 1966, and Oct. 31, 2010. Fifteen studies reported on pharmacist-related interventions; six reported on technology-specific interventions; and five reported on other types of interventions, including staff education and use of standardized med-rec tools.

Analysis of these studies revealed that all of these interventions successfully decreased medication discrepancies and potential adverse drug events, but there was inconsistent benefit with regard to adverse drug events and healthcare utilization compared with usual care. The literature was most supportive of pharmacist-related interventions, including but not limited to comprehensive medication history at admission, med rec at discharge, patient counseling, discharge communication with outpatient providers, and post-discharge communication with the patient and post-hospital providers.

Bottom line: Successful med rec requires multiple interventions at various transitions of care and involves a variety of medical professionals. Patient-targeted interventions, including pharmacists, have the potential to decrease errors and adverse events.

Citation: Mueller S, Sponsler K, Kripalani S, Schnipper J. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-1069.

Clinical question: Which clinical decision rule—Wells rule, simplified Wells rule, revised Geneva score, or simplified revised Geneva score—is the best for evaluating a patient with a possible acute pulmonary embolism?

Background: The use of standardized clinical decision rules to determine the probability of an acute pulmonary embolism (PE) has significantly improved the diagnostic evaluation of patients with suspected PE. Several clinical decision rules are available and widely used, but they have not been previously directly compared.

Study design: Prospective cohort.

Setting: Seven hospitals in the Netherlands.

Synopsis: A total of 807 patients with suspected first episode of acute PE had a sequential workup with clinical probability assessment and D-dimer testing. When PE was considered unlikely according to all four clinical decision rules and a normal D-dimer result, PE was excluded. In the remaining patients, a CT scan was used to confirm or exclude the diagnosis.

The prevalence of PE was 23%. Combined with a normal D-dimer, the decision rules excluded PE in 22% to 24% of patients. Thirty percent of patients had discordant decision rule outcomes, but PE was not detected by CT in any of these patients when combined with a normal D-dimer.

This study has practical limitations because management was based on a combination of four decision rules and D-dimer testing rather than only one rule and D-dimer testing, which is the more realistic clinical approach.

Bottom line: When used correctly and in conjunction with a D-dimer result, the Wells rule, simplified Wells rule, revised Geneva score, and simplified revised Geneva score all perform similarly in the exclusion of acute PE.

Citation: Douma RA, Mos IC, Erkens PM, et al. Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study. Ann Intern Med. 2011;154:709-718.

For more of physician reviews of HM-related literature, check out this month's"In the Literature".

Clinical question: Which clinical decision rule—Wells rule, simplified Wells rule, revised Geneva score, or simplified revised Geneva score—is the best for evaluating a patient with a possible acute pulmonary embolism?

Background: The use of standardized clinical decision rules to determine the probability of an acute pulmonary embolism (PE) has significantly improved the diagnostic evaluation of patients with suspected PE. Several clinical decision rules are available and widely used, but they have not been previously directly compared.

Study design: Prospective cohort.

Setting: Seven hospitals in the Netherlands.

Synopsis: A total of 807 patients with suspected first episode of acute PE had a sequential workup with clinical probability assessment and D-dimer testing. When PE was considered unlikely according to all four clinical decision rules and a normal D-dimer result, PE was excluded. In the remaining patients, a CT scan was used to confirm or exclude the diagnosis.

The prevalence of PE was 23%. Combined with a normal D-dimer, the decision rules excluded PE in 22% to 24% of patients. Thirty percent of patients had discordant decision rule outcomes, but PE was not detected by CT in any of these patients when combined with a normal D-dimer.

This study has practical limitations because management was based on a combination of four decision rules and D-dimer testing rather than only one rule and D-dimer testing, which is the more realistic clinical approach.

Bottom line: When used correctly and in conjunction with a D-dimer result, the Wells rule, simplified Wells rule, revised Geneva score, and simplified revised Geneva score all perform similarly in the exclusion of acute PE.

Citation: Douma RA, Mos IC, Erkens PM, et al. Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study. Ann Intern Med. 2011;154:709-718.

For more of physician reviews of HM-related literature, check out this month's"In the Literature".

Clinical question: Which clinical decision rule—Wells rule, simplified Wells rule, revised Geneva score, or simplified revised Geneva score—is the best for evaluating a patient with a possible acute pulmonary embolism?

Background: The use of standardized clinical decision rules to determine the probability of an acute pulmonary embolism (PE) has significantly improved the diagnostic evaluation of patients with suspected PE. Several clinical decision rules are available and widely used, but they have not been previously directly compared.

Study design: Prospective cohort.

Setting: Seven hospitals in the Netherlands.

Synopsis: A total of 807 patients with suspected first episode of acute PE had a sequential workup with clinical probability assessment and D-dimer testing. When PE was considered unlikely according to all four clinical decision rules and a normal D-dimer result, PE was excluded. In the remaining patients, a CT scan was used to confirm or exclude the diagnosis.

The prevalence of PE was 23%. Combined with a normal D-dimer, the decision rules excluded PE in 22% to 24% of patients. Thirty percent of patients had discordant decision rule outcomes, but PE was not detected by CT in any of these patients when combined with a normal D-dimer.

This study has practical limitations because management was based on a combination of four decision rules and D-dimer testing rather than only one rule and D-dimer testing, which is the more realistic clinical approach.

Bottom line: When used correctly and in conjunction with a D-dimer result, the Wells rule, simplified Wells rule, revised Geneva score, and simplified revised Geneva score all perform similarly in the exclusion of acute PE.

Citation: Douma RA, Mos IC, Erkens PM, et al. Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study. Ann Intern Med. 2011;154:709-718.

For more of physician reviews of HM-related literature, check out this month's"In the Literature".

Clinical question: When do venous thromboembolism (VTE) events occur after cancer surgery?

Background: Cancer is a known risk factor for VTE. Prophylaxis for VTE after cancer surgery is commonly stopped at the time of hospital discharge despite evidence for extended-duration treatment.

Study design: Retrospective cohort.

Setting: Patients reported to the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.

Synopsis: The authors examined the records of 46,656 patients who underwent surgery for one of nine specified cancers. Overall VTE rate was 1.6% (1.0% deep venous thrombosis and 0.6% pulmonary embolism), with 33.4% of VTE events occurring after hospital discharge. VTE risk was highest after esophagogastric and hepatopancreaticobiliary surgery, followed by lung, rectum, ovary/uterus, colon, and prostate. Breast and thyroid/parathyroid surgeries had the lowest incidence of VTE. VTE was associated with increased 30-day mortality. Use of VTE prophylaxis during or after hospitalization was not recorded.

Bottom line: Elevated VTE risk persists following hospital discharge after cancer surgery and consideration should be given to extended-duration thromboprophylaxis. Optimal duration of prophylaxis and its risks and benefits remain poorly defined.

Citation: Merkow RP, Bilimoria KY, McCarter MD, et al. Post-discharge venous thromboembolism after cancer surgery: extending the case for extended prophylaxis. Ann Surg. 2011;254:131-137.

For more physician reviews of HM-related literature, visit our website.

Clinical question: When do venous thromboembolism (VTE) events occur after cancer surgery?

Background: Cancer is a known risk factor for VTE. Prophylaxis for VTE after cancer surgery is commonly stopped at the time of hospital discharge despite evidence for extended-duration treatment.

Study design: Retrospective cohort.

Setting: Patients reported to the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.

Synopsis: The authors examined the records of 46,656 patients who underwent surgery for one of nine specified cancers. Overall VTE rate was 1.6% (1.0% deep venous thrombosis and 0.6% pulmonary embolism), with 33.4% of VTE events occurring after hospital discharge. VTE risk was highest after esophagogastric and hepatopancreaticobiliary surgery, followed by lung, rectum, ovary/uterus, colon, and prostate. Breast and thyroid/parathyroid surgeries had the lowest incidence of VTE. VTE was associated with increased 30-day mortality. Use of VTE prophylaxis during or after hospitalization was not recorded.

Bottom line: Elevated VTE risk persists following hospital discharge after cancer surgery and consideration should be given to extended-duration thromboprophylaxis. Optimal duration of prophylaxis and its risks and benefits remain poorly defined.

Citation: Merkow RP, Bilimoria KY, McCarter MD, et al. Post-discharge venous thromboembolism after cancer surgery: extending the case for extended prophylaxis. Ann Surg. 2011;254:131-137.

For more physician reviews of HM-related literature, visit our website.

Clinical question: When do venous thromboembolism (VTE) events occur after cancer surgery?

Background: Cancer is a known risk factor for VTE. Prophylaxis for VTE after cancer surgery is commonly stopped at the time of hospital discharge despite evidence for extended-duration treatment.

Study design: Retrospective cohort.

Setting: Patients reported to the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.

Synopsis: The authors examined the records of 46,656 patients who underwent surgery for one of nine specified cancers. Overall VTE rate was 1.6% (1.0% deep venous thrombosis and 0.6% pulmonary embolism), with 33.4% of VTE events occurring after hospital discharge. VTE risk was highest after esophagogastric and hepatopancreaticobiliary surgery, followed by lung, rectum, ovary/uterus, colon, and prostate. Breast and thyroid/parathyroid surgeries had the lowest incidence of VTE. VTE was associated with increased 30-day mortality. Use of VTE prophylaxis during or after hospitalization was not recorded.

Bottom line: Elevated VTE risk persists following hospital discharge after cancer surgery and consideration should be given to extended-duration thromboprophylaxis. Optimal duration of prophylaxis and its risks and benefits remain poorly defined.

Citation: Merkow RP, Bilimoria KY, McCarter MD, et al. Post-discharge venous thromboembolism after cancer surgery: extending the case for extended prophylaxis. Ann Surg. 2011;254:131-137.

For more physician reviews of HM-related literature, visit our website.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Use of a Care-Transitions Intervention Reduces 30-Day Hospital Readmissions
2. Routine Chest Radiographs after Pneumonia to Rule Out Lung Cancer Have Low Diagnostic Yield
3. Hospitalist Care Shifts Costs to the Outpatient Environment
4. Stopping Smoking at Any Time before Surgery Is Safe
5. Hospitalization for Infection Increases Risk of Stroke
6. Longer Duration of Perioperative Antibiotics May Be Beneficial after Cardiac Surgery
7. Stroke Unit Care Combined with Early Supported Discharge Improves Outcomes
8. Criteria May Help Identify Patients at Risk for Infective Endocarditis

Use of a Care-Transitions Intervention Reduces 30-Day Hospital Readmissions

Clinical question: Does use of a specific care-transitions intervention (CTI) reduce 30-day hospital readmissions in a nonintegrated healthcare system?

Background: Previous interventions addressing improved communication between members of the healthcare team, patients, and families at time of discharge show promise for reducing hospital readmissions. Although these interventions revealed positive results, no research has been completed within a system where healthcare is integrated across settings.

Study design: Quasi-experimental prospective cohort study.

Setting: Six Rhode Island acute-care hospitals, including two community hospitals, three teaching hospitals, and a tertiary-care center and teaching hospital. Facilities ranged from 129 beds to 719 beds.

Synopsis: The CTI is a patient-centered intervention occurring across 30 days. The intervention includes a home visit by a coach within three days of hospital discharge, a telephone call within seven to 10 days of discharge, and a final telephone call no later than 30 days after admission. During these contacts, coaches encourage patient and family participation in care, and active communication with their primary-care provider regarding their disease state. A convenience sample of fee-for-service Medicare beneficiaries was identified by admission diagnoses of acute myocardial infarction, congestive heart failure, or specific pulmonary conditions. Overall, 74% participants completed the entire intervention. The odds of a hospital readmission were significantly lower in the intervention population compared with those who did not receive the intervention (OR 0.61; 95% CI, 0.42-0.88).

Study design: Study design was limited by ability to provide coaching (only 8% of total population was approached), and therefore may not be representative of a typical integrated healthcare setting. In addition, the sample consisted of a convenience sample, which may limit generalizability.

Bottom line: The CTI appears to decrease the rate of 30-day hospital readmissions in Medicare patients with certain cardiac and pulmonary diagnoses.

Citation: Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. The care transitions intervention: translating from efficacy to effectiveness. Arch Intern Med. 2011;171:1232-1237.

Routine Chest Radiographs after Pneumonia to Rule Out Lung Cancer Have Low Diagnostic Yield

Clinical question: What is the incidence of new lung cancer detected on routine post-pneumonia chest radiographs?

Background: Routine chest radiographs have been recommended four to eight weeks after resolution of pneumonia to exclude underlying lung cancer. The diagnostic yield of this practice is uncertain.

Study design: Population-based cohort.

Setting: Seven emergency departments and six hospitals in Edmonton, Alberta, Canada.

Synopsis: Authors enrolled 3,398 patients with clinical and radiographic evidence of pneumonia. Of these, 59% were aged 50 and older, 52% were male, 17% were current smokers, 18% had COPD, and 49% were treated as inpatients. At 90-day follow-up, 1.1% of patients received a new diagnosis of lung cancer, with incidence steadily increasing to 2.2% at three-year follow-up. In multivariate analysis, age 50 and older, male sex, and current smoking were independent predictors of post-pneumonia new lung cancer diagnosis. Limiting follow-up chest radiographs to patients aged 50 and older would have detected 98% of new lung cancers and improved diagnostic yield to 2.8%.

Bottom line: Routine post-pneumonia chest radiographs for lung cancer screening have low diagnostic yield that is only marginally improved by selecting high-risk populations.

Citation: Tang KL, Eurich DT, Minhas-Sandhu JK, Marrie TJ, Majumdar SR. Incidence, correlates, and chest radiographic yield of new lung cancer diagnosis in 3398 patients with pneumonia. Arch Intern Med. 2011;171:1193-1198.

Hospitalist Care Shifts Costs to the Outpatient Environment

Clinical question: How does hospitalist care affect medical utilization costs after hospital discharge?

Background: The number of patients cared for by hospitalists is growing rapidly. Some studies have shown hospitalists to decrease length of stay and inpatient costs. The impact of shorter hospitalization on outpatient medical utilization and costs is not known.

Study design: Population-based national cohort.

Setting: Hospitalized Medicare patients.

Synopsis: In this study of 58,125 Medicare admissions at 454 hospitals, hospitalist care was associated with a 0.64-day shorter adjusted length of stay and $282 lower hospital charges compared with patients cared for by their primary-care physicians (PCPs). This was offset by $332 higher Medicare spending in the 30 days following hospitalization. Patients cared for by hospitalists were less likely to be discharged home (OR 0.82, 95% CI, 0.78-0.86), and were more likely to require emergency department visits (OR 1.18, 95% CI, 1.12-1.24) and readmissions (OR 1.08, 95% CI, 1.02-1.14). The authors postulate that shorter length of stay associated with hospitalist care is achieved at the expense of shifting costs to the outpatient environment. The discharged patients are sicker and, as a result, require more skilled care and repeat hospital visits.

Bottom line: Hospitalist care may be associated with higher overall costs and more medical utilization.

Citation: Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152-159.

Stopping Smoking at Any Time before Surgery Is Safe

Clinical question: Is smoking cessation within eight weeks of surgery safe?

Background: Smoking cessation before surgery can decrease the risk of surgical complications. However, several studies found increased risk for perioperative complications when smoking was stopped within eight weeks of surgery. These findings created uncertainty about general safety of tobacco cessation counseling before surgery.

Study design: Systematic review and meta-analysis.

Setting: Smokers undergoing any type of surgery.

Synopsis: The authors identified nine studies involving 889 patients that compared smokers who quit within eight weeks of surgery with those who continued to smoke. There was considerable heterogeneity in the studies but no overall difference in perioperative complications between those who quit smoking and those who continued to smoke (OR 0.78, 95% CI, 0.57-1.07). The subset of studies examining pulmonary complications also found no difference (OR 1.18, 95% CI, 0.95-1.46).

Bottom line: Smoking cessation at any time before surgery appears to be safe.

Citation: Myers K, Hajek P, Hinds C, McRobbie H. Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis. Arch Intern Med. 2011;171:983-989.

Hospitalization for Infection Increases Risk of Stroke

Clinical question: Can infection act as a precipitant for acute ischemic stroke?

Background: Little is known about precipitants of acute ischemic stroke. Severe infections have been shown to promote hypercoagulability and platelet activation, and to induce endothelial dysfunction. Authors postulated that infections severe enough to warrant hospitalization might transiently increase the risk for stroke.

Study design: Case-crossover analysis of data from a multicenter prospective cohort (Cardiovascular Health Study).

Setting: Medicare patients in four communities.

Synopsis: During a median follow-up of 12.2 years, 669 strokes occurred in 5,639 study participants. Hospitalization for infection within 14 days was associated with increased risk of stroke (OR 8.0, 95% CI, 1.6-77.3), and the risk remained elevated for hospitalizations within 90 days (OR 3.4, 95% CI, 1.8-6.5). The findings remained significant after adjusting for comorbidities, including age, sex, race, smoking, and diabetes. The number of patients hospitalized for infection before stroke was small—eight within 14 days, and 29 within 90 days.

Bottom line: Infection severe enough to require hospitalization may act as a trigger for acute ischemic stroke.

Citation: Elkind MS, Carty CL, O’Meara ES, et al. Hospitalization for infection and risk of acute ischemic stroke: the Cardiovascular Health Study. Stroke. 2011;42:1851-1856.

Longer Duration of Perioperative Antibiotics May Be Beneficial after Cardiac Surgery

Clinical question: Is antibiotic prophylaxis for 24 or more hours better than shorter duration of treatment after cardiac surgery?

Background: Sternal surgical site infections are a serious complication of cardiac surgery. The optimal duration of perioperative antibiotic prophylaxis is not known, with recommendations ranging from a single dose to 72 hours. The Society of Thoracic Surgeons’ recommendation for 24 to 72 hours of prophylaxis is not based on a systematic review and meta-analysis.

Study design: Systematic review and meta-analysis.

Setting: Adult patients undergoing open-heart surgery who received perioperative antibiotic prophylaxis.

Synopsis: Authors identified 12 trials encompassing 7,893 patients. Compared with prophylaxis of ≥24 hours, prophylaxis of <24 hours was associated with a higher risk of sternal surgical site infections (RR 1.38, 95% CI, 1.13-1.69) and deep infections (RR 1.68, 95% CI, 1.12-2.53). There was no difference in mortality, other infections, or adverse events. Most studies had methodological limitations with a high risk for bias.

Bottom line: Perioperative antibiotic prophylaxis of ≥24 hours reduces sternal surgical infections.

Citation: Mertz D, Johnstone J, Loeb M. Does duration of perioperative antibiotic prophylaxis matter in cardiac surgery? A systematic review and meta-analysis. Ann Surg. 2011;254:48-54.

Stroke Unit Care Combined with Early Supported Discharge Improves Outcomes

Clinical question: Does early supported discharge (ESD) improve outcomes more than conventional follow-up in stroke patients?

Background: ESD is a mobile team that coordinates follow-up and rehabilitation. Previous studies have shown it to be beneficial in patients with mild to moderate disability at one year, but long-term effects of ESD are not known.

Study design: Randomized controlled trial.

Setting: Single center in Norway.

Synopsis: Stroke-unit patients were recruited and received standard care or ESD after discharge. All 320 patients received standard acute care. The proportion of patients with modified Rankin Score (mRS) of ≤2 was not significantly different in the two groups but identified a trend toward improvement in the intervention group (38% vs. 30%, P=0.106). More patients receiving conventional follow-up died or were institutionalized (P=0.032) but mortality rates at five years were similar (ESD 46% vs. 51%). Secondary outcomes (Scandinavian Stroke Scale, Barthel Index, Frenchay Activity Index, and Mini Mental Status Examination) were not statistically different. Predictors of good outcome in the ESD group included young age, low mRS, and living with others.

This study recruited patients from 1995 to 1997 and followed the patients for five years. Limitations to the applicability include advances in stroke rehabilitation in the last 10 years. The cost of a mobile multidisciplinary team consisting of a physiotherapist, occupational therapist, nurse, and part-time physician was not discussed and may limit the availability to many patients.

Bottom line: Early supported discharge may increase the proportion of patients living at home five years after stroke.

Citation: Fjaertoft H, Rohweder G, Indredavik B. Stroke unit care combined with early supported discharge improves 5-year outcome: a randomized controlled trial. Stroke. 2011;42:1707-1711.

Criteria May Help Identify Patients at Risk for Infective Endocarditis

Clinical question: Which patients with Staphylococcus aureus bacteremia benefit the most from transesophageal echocardiography?

Background: Infective endocarditis is a serious complication of S. aureus bacteremia (SAB), occurring in 5% to 17% of patients with documented SAB. It has been recommended to perform transesophageal echocardiography (TEE) in all patients with SAB. Large variation exists in rates of TEE, and identifying patients at low risk for endocarditis may help with more appropriate utilization of this test.

Study design: Retrospective cohort analysis.

Setting: Two university-based German tertiary hospitals (INSTINCT cohort) and one North American university-based hospital from October 1994 to December 2009 (SABG cohort).

Synopsis: A total of 736 cases of nosocomial SAB were analyzed. Age, source of infection, and 30-day and 90-day case fatality rates were similar between the two cohorts. Patients were followed during the index hospitalization and for three months after discharge.

Patients with infective endocarditis were more likely to have prolonged bacteremia; a permanent intracardiac device, such as a pacemaker or a heart valve; be recipients of hemodialysis; and have osteomyelitis. Of the 83 patients who did not fulfill any of the prediction criteria, no cases of infective endocarditis were found.

Bottom line: A set of simple criteria may help identify patients with nosocomial SAB who are at risk for infective endocarditis. The subset of patients who do not meet any of these criteria may not need diagnostic evaluation with TEE.

Citation: Kaasch, AJ, Fowler VG Jr., Rieg S, et al. Use of a simple criteria set for guiding echocardiography in nosocomial Staphylococcus aureus bacteremia. Clin Infect Dis. 2011;53:1-9.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Use of a Care-Transitions Intervention Reduces 30-Day Hospital Readmissions
2. Routine Chest Radiographs after Pneumonia to Rule Out Lung Cancer Have Low Diagnostic Yield
3. Hospitalist Care Shifts Costs to the Outpatient Environment
4. Stopping Smoking at Any Time before Surgery Is Safe
5. Hospitalization for Infection Increases Risk of Stroke
6. Longer Duration of Perioperative Antibiotics May Be Beneficial after Cardiac Surgery
7. Stroke Unit Care Combined with Early Supported Discharge Improves Outcomes
8. Criteria May Help Identify Patients at Risk for Infective Endocarditis

Use of a Care-Transitions Intervention Reduces 30-Day Hospital Readmissions

Clinical question: Does use of a specific care-transitions intervention (CTI) reduce 30-day hospital readmissions in a nonintegrated healthcare system?

Background: Previous interventions addressing improved communication between members of the healthcare team, patients, and families at time of discharge show promise for reducing hospital readmissions. Although these interventions revealed positive results, no research has been completed within a system where healthcare is integrated across settings.

Study design: Quasi-experimental prospective cohort study.

Setting: Six Rhode Island acute-care hospitals, including two community hospitals, three teaching hospitals, and a tertiary-care center and teaching hospital. Facilities ranged from 129 beds to 719 beds.

Synopsis: The CTI is a patient-centered intervention occurring across 30 days. The intervention includes a home visit by a coach within three days of hospital discharge, a telephone call within seven to 10 days of discharge, and a final telephone call no later than 30 days after admission. During these contacts, coaches encourage patient and family participation in care, and active communication with their primary-care provider regarding their disease state. A convenience sample of fee-for-service Medicare beneficiaries was identified by admission diagnoses of acute myocardial infarction, congestive heart failure, or specific pulmonary conditions. Overall, 74% participants completed the entire intervention. The odds of a hospital readmission were significantly lower in the intervention population compared with those who did not receive the intervention (OR 0.61; 95% CI, 0.42-0.88).

Study design: Study design was limited by ability to provide coaching (only 8% of total population was approached), and therefore may not be representative of a typical integrated healthcare setting. In addition, the sample consisted of a convenience sample, which may limit generalizability.

Bottom line: The CTI appears to decrease the rate of 30-day hospital readmissions in Medicare patients with certain cardiac and pulmonary diagnoses.

Citation: Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. The care transitions intervention: translating from efficacy to effectiveness. Arch Intern Med. 2011;171:1232-1237.

Routine Chest Radiographs after Pneumonia to Rule Out Lung Cancer Have Low Diagnostic Yield

Clinical question: What is the incidence of new lung cancer detected on routine post-pneumonia chest radiographs?

Background: Routine chest radiographs have been recommended four to eight weeks after resolution of pneumonia to exclude underlying lung cancer. The diagnostic yield of this practice is uncertain.

Study design: Population-based cohort.

Setting: Seven emergency departments and six hospitals in Edmonton, Alberta, Canada.

Synopsis: Authors enrolled 3,398 patients with clinical and radiographic evidence of pneumonia. Of these, 59% were aged 50 and older, 52% were male, 17% were current smokers, 18% had COPD, and 49% were treated as inpatients. At 90-day follow-up, 1.1% of patients received a new diagnosis of lung cancer, with incidence steadily increasing to 2.2% at three-year follow-up. In multivariate analysis, age 50 and older, male sex, and current smoking were independent predictors of post-pneumonia new lung cancer diagnosis. Limiting follow-up chest radiographs to patients aged 50 and older would have detected 98% of new lung cancers and improved diagnostic yield to 2.8%.

Bottom line: Routine post-pneumonia chest radiographs for lung cancer screening have low diagnostic yield that is only marginally improved by selecting high-risk populations.

Citation: Tang KL, Eurich DT, Minhas-Sandhu JK, Marrie TJ, Majumdar SR. Incidence, correlates, and chest radiographic yield of new lung cancer diagnosis in 3398 patients with pneumonia. Arch Intern Med. 2011;171:1193-1198.

Hospitalist Care Shifts Costs to the Outpatient Environment

Clinical question: How does hospitalist care affect medical utilization costs after hospital discharge?

Background: The number of patients cared for by hospitalists is growing rapidly. Some studies have shown hospitalists to decrease length of stay and inpatient costs. The impact of shorter hospitalization on outpatient medical utilization and costs is not known.

Study design: Population-based national cohort.

Setting: Hospitalized Medicare patients.

Synopsis: In this study of 58,125 Medicare admissions at 454 hospitals, hospitalist care was associated with a 0.64-day shorter adjusted length of stay and $282 lower hospital charges compared with patients cared for by their primary-care physicians (PCPs). This was offset by $332 higher Medicare spending in the 30 days following hospitalization. Patients cared for by hospitalists were less likely to be discharged home (OR 0.82, 95% CI, 0.78-0.86), and were more likely to require emergency department visits (OR 1.18, 95% CI, 1.12-1.24) and readmissions (OR 1.08, 95% CI, 1.02-1.14). The authors postulate that shorter length of stay associated with hospitalist care is achieved at the expense of shifting costs to the outpatient environment. The discharged patients are sicker and, as a result, require more skilled care and repeat hospital visits.

Bottom line: Hospitalist care may be associated with higher overall costs and more medical utilization.

Citation: Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152-159.

Stopping Smoking at Any Time before Surgery Is Safe

Clinical question: Is smoking cessation within eight weeks of surgery safe?

Background: Smoking cessation before surgery can decrease the risk of surgical complications. However, several studies found increased risk for perioperative complications when smoking was stopped within eight weeks of surgery. These findings created uncertainty about general safety of tobacco cessation counseling before surgery.

Study design: Systematic review and meta-analysis.

Setting: Smokers undergoing any type of surgery.

Synopsis: The authors identified nine studies involving 889 patients that compared smokers who quit within eight weeks of surgery with those who continued to smoke. There was considerable heterogeneity in the studies but no overall difference in perioperative complications between those who quit smoking and those who continued to smoke (OR 0.78, 95% CI, 0.57-1.07). The subset of studies examining pulmonary complications also found no difference (OR 1.18, 95% CI, 0.95-1.46).

Bottom line: Smoking cessation at any time before surgery appears to be safe.

Citation: Myers K, Hajek P, Hinds C, McRobbie H. Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis. Arch Intern Med. 2011;171:983-989.

Hospitalization for Infection Increases Risk of Stroke

Clinical question: Can infection act as a precipitant for acute ischemic stroke?

Background: Little is known about precipitants of acute ischemic stroke. Severe infections have been shown to promote hypercoagulability and platelet activation, and to induce endothelial dysfunction. Authors postulated that infections severe enough to warrant hospitalization might transiently increase the risk for stroke.

Study design: Case-crossover analysis of data from a multicenter prospective cohort (Cardiovascular Health Study).

Setting: Medicare patients in four communities.

Synopsis: During a median follow-up of 12.2 years, 669 strokes occurred in 5,639 study participants. Hospitalization for infection within 14 days was associated with increased risk of stroke (OR 8.0, 95% CI, 1.6-77.3), and the risk remained elevated for hospitalizations within 90 days (OR 3.4, 95% CI, 1.8-6.5). The findings remained significant after adjusting for comorbidities, including age, sex, race, smoking, and diabetes. The number of patients hospitalized for infection before stroke was small—eight within 14 days, and 29 within 90 days.

Bottom line: Infection severe enough to require hospitalization may act as a trigger for acute ischemic stroke.

Citation: Elkind MS, Carty CL, O’Meara ES, et al. Hospitalization for infection and risk of acute ischemic stroke: the Cardiovascular Health Study. Stroke. 2011;42:1851-1856.

Longer Duration of Perioperative Antibiotics May Be Beneficial after Cardiac Surgery

Clinical question: Is antibiotic prophylaxis for 24 or more hours better than shorter duration of treatment after cardiac surgery?

Background: Sternal surgical site infections are a serious complication of cardiac surgery. The optimal duration of perioperative antibiotic prophylaxis is not known, with recommendations ranging from a single dose to 72 hours. The Society of Thoracic Surgeons’ recommendation for 24 to 72 hours of prophylaxis is not based on a systematic review and meta-analysis.

Study design: Systematic review and meta-analysis.

Setting: Adult patients undergoing open-heart surgery who received perioperative antibiotic prophylaxis.

Synopsis: Authors identified 12 trials encompassing 7,893 patients. Compared with prophylaxis of ≥24 hours, prophylaxis of <24 hours was associated with a higher risk of sternal surgical site infections (RR 1.38, 95% CI, 1.13-1.69) and deep infections (RR 1.68, 95% CI, 1.12-2.53). There was no difference in mortality, other infections, or adverse events. Most studies had methodological limitations with a high risk for bias.

Bottom line: Perioperative antibiotic prophylaxis of ≥24 hours reduces sternal surgical infections.

Citation: Mertz D, Johnstone J, Loeb M. Does duration of perioperative antibiotic prophylaxis matter in cardiac surgery? A systematic review and meta-analysis. Ann Surg. 2011;254:48-54.

Stroke Unit Care Combined with Early Supported Discharge Improves Outcomes

Clinical question: Does early supported discharge (ESD) improve outcomes more than conventional follow-up in stroke patients?

Background: ESD is a mobile team that coordinates follow-up and rehabilitation. Previous studies have shown it to be beneficial in patients with mild to moderate disability at one year, but long-term effects of ESD are not known.

Study design: Randomized controlled trial.

Setting: Single center in Norway.

Synopsis: Stroke-unit patients were recruited and received standard care or ESD after discharge. All 320 patients received standard acute care. The proportion of patients with modified Rankin Score (mRS) of ≤2 was not significantly different in the two groups but identified a trend toward improvement in the intervention group (38% vs. 30%, P=0.106). More patients receiving conventional follow-up died or were institutionalized (P=0.032) but mortality rates at five years were similar (ESD 46% vs. 51%). Secondary outcomes (Scandinavian Stroke Scale, Barthel Index, Frenchay Activity Index, and Mini Mental Status Examination) were not statistically different. Predictors of good outcome in the ESD group included young age, low mRS, and living with others.

This study recruited patients from 1995 to 1997 and followed the patients for five years. Limitations to the applicability include advances in stroke rehabilitation in the last 10 years. The cost of a mobile multidisciplinary team consisting of a physiotherapist, occupational therapist, nurse, and part-time physician was not discussed and may limit the availability to many patients.

Bottom line: Early supported discharge may increase the proportion of patients living at home five years after stroke.

Citation: Fjaertoft H, Rohweder G, Indredavik B. Stroke unit care combined with early supported discharge improves 5-year outcome: a randomized controlled trial. Stroke. 2011;42:1707-1711.

Criteria May Help Identify Patients at Risk for Infective Endocarditis

Clinical question: Which patients with Staphylococcus aureus bacteremia benefit the most from transesophageal echocardiography?

Background: Infective endocarditis is a serious complication of S. aureus bacteremia (SAB), occurring in 5% to 17% of patients with documented SAB. It has been recommended to perform transesophageal echocardiography (TEE) in all patients with SAB. Large variation exists in rates of TEE, and identifying patients at low risk for endocarditis may help with more appropriate utilization of this test.

Study design: Retrospective cohort analysis.

Setting: Two university-based German tertiary hospitals (INSTINCT cohort) and one North American university-based hospital from October 1994 to December 2009 (SABG cohort).

Synopsis: A total of 736 cases of nosocomial SAB were analyzed. Age, source of infection, and 30-day and 90-day case fatality rates were similar between the two cohorts. Patients were followed during the index hospitalization and for three months after discharge.

Patients with infective endocarditis were more likely to have prolonged bacteremia; a permanent intracardiac device, such as a pacemaker or a heart valve; be recipients of hemodialysis; and have osteomyelitis. Of the 83 patients who did not fulfill any of the prediction criteria, no cases of infective endocarditis were found.

Bottom line: A set of simple criteria may help identify patients with nosocomial SAB who are at risk for infective endocarditis. The subset of patients who do not meet any of these criteria may not need diagnostic evaluation with TEE.

Citation: Kaasch, AJ, Fowler VG Jr., Rieg S, et al. Use of a simple criteria set for guiding echocardiography in nosocomial Staphylococcus aureus bacteremia. Clin Infect Dis. 2011;53:1-9.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Use of a Care-Transitions Intervention Reduces 30-Day Hospital Readmissions
2. Routine Chest Radiographs after Pneumonia to Rule Out Lung Cancer Have Low Diagnostic Yield
3. Hospitalist Care Shifts Costs to the Outpatient Environment
4. Stopping Smoking at Any Time before Surgery Is Safe
5. Hospitalization for Infection Increases Risk of Stroke
6. Longer Duration of Perioperative Antibiotics May Be Beneficial after Cardiac Surgery
7. Stroke Unit Care Combined with Early Supported Discharge Improves Outcomes
8. Criteria May Help Identify Patients at Risk for Infective Endocarditis

Use of a Care-Transitions Intervention Reduces 30-Day Hospital Readmissions

Clinical question: Does use of a specific care-transitions intervention (CTI) reduce 30-day hospital readmissions in a nonintegrated healthcare system?

Background: Previous interventions addressing improved communication between members of the healthcare team, patients, and families at time of discharge show promise for reducing hospital readmissions. Although these interventions revealed positive results, no research has been completed within a system where healthcare is integrated across settings.

Study design: Quasi-experimental prospective cohort study.

Setting: Six Rhode Island acute-care hospitals, including two community hospitals, three teaching hospitals, and a tertiary-care center and teaching hospital. Facilities ranged from 129 beds to 719 beds.

Synopsis: The CTI is a patient-centered intervention occurring across 30 days. The intervention includes a home visit by a coach within three days of hospital discharge, a telephone call within seven to 10 days of discharge, and a final telephone call no later than 30 days after admission. During these contacts, coaches encourage patient and family participation in care, and active communication with their primary-care provider regarding their disease state. A convenience sample of fee-for-service Medicare beneficiaries was identified by admission diagnoses of acute myocardial infarction, congestive heart failure, or specific pulmonary conditions. Overall, 74% participants completed the entire intervention. The odds of a hospital readmission were significantly lower in the intervention population compared with those who did not receive the intervention (OR 0.61; 95% CI, 0.42-0.88).

Study design: Study design was limited by ability to provide coaching (only 8% of total population was approached), and therefore may not be representative of a typical integrated healthcare setting. In addition, the sample consisted of a convenience sample, which may limit generalizability.

Bottom line: The CTI appears to decrease the rate of 30-day hospital readmissions in Medicare patients with certain cardiac and pulmonary diagnoses.

Citation: Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. The care transitions intervention: translating from efficacy to effectiveness. Arch Intern Med. 2011;171:1232-1237.

Routine Chest Radiographs after Pneumonia to Rule Out Lung Cancer Have Low Diagnostic Yield

Clinical question: What is the incidence of new lung cancer detected on routine post-pneumonia chest radiographs?

Background: Routine chest radiographs have been recommended four to eight weeks after resolution of pneumonia to exclude underlying lung cancer. The diagnostic yield of this practice is uncertain.

Study design: Population-based cohort.

Setting: Seven emergency departments and six hospitals in Edmonton, Alberta, Canada.

Synopsis: Authors enrolled 3,398 patients with clinical and radiographic evidence of pneumonia. Of these, 59% were aged 50 and older, 52% were male, 17% were current smokers, 18% had COPD, and 49% were treated as inpatients. At 90-day follow-up, 1.1% of patients received a new diagnosis of lung cancer, with incidence steadily increasing to 2.2% at three-year follow-up. In multivariate analysis, age 50 and older, male sex, and current smoking were independent predictors of post-pneumonia new lung cancer diagnosis. Limiting follow-up chest radiographs to patients aged 50 and older would have detected 98% of new lung cancers and improved diagnostic yield to 2.8%.

Bottom line: Routine post-pneumonia chest radiographs for lung cancer screening have low diagnostic yield that is only marginally improved by selecting high-risk populations.

Citation: Tang KL, Eurich DT, Minhas-Sandhu JK, Marrie TJ, Majumdar SR. Incidence, correlates, and chest radiographic yield of new lung cancer diagnosis in 3398 patients with pneumonia. Arch Intern Med. 2011;171:1193-1198.

Hospitalist Care Shifts Costs to the Outpatient Environment

Clinical question: How does hospitalist care affect medical utilization costs after hospital discharge?

Background: The number of patients cared for by hospitalists is growing rapidly. Some studies have shown hospitalists to decrease length of stay and inpatient costs. The impact of shorter hospitalization on outpatient medical utilization and costs is not known.

Study design: Population-based national cohort.

Setting: Hospitalized Medicare patients.

Synopsis: In this study of 58,125 Medicare admissions at 454 hospitals, hospitalist care was associated with a 0.64-day shorter adjusted length of stay and $282 lower hospital charges compared with patients cared for by their primary-care physicians (PCPs). This was offset by $332 higher Medicare spending in the 30 days following hospitalization. Patients cared for by hospitalists were less likely to be discharged home (OR 0.82, 95% CI, 0.78-0.86), and were more likely to require emergency department visits (OR 1.18, 95% CI, 1.12-1.24) and readmissions (OR 1.08, 95% CI, 1.02-1.14). The authors postulate that shorter length of stay associated with hospitalist care is achieved at the expense of shifting costs to the outpatient environment. The discharged patients are sicker and, as a result, require more skilled care and repeat hospital visits.

Bottom line: Hospitalist care may be associated with higher overall costs and more medical utilization.

Citation: Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152-159.

Stopping Smoking at Any Time before Surgery Is Safe

Clinical question: Is smoking cessation within eight weeks of surgery safe?

Background: Smoking cessation before surgery can decrease the risk of surgical complications. However, several studies found increased risk for perioperative complications when smoking was stopped within eight weeks of surgery. These findings created uncertainty about general safety of tobacco cessation counseling before surgery.

Study design: Systematic review and meta-analysis.

Setting: Smokers undergoing any type of surgery.

Synopsis: The authors identified nine studies involving 889 patients that compared smokers who quit within eight weeks of surgery with those who continued to smoke. There was considerable heterogeneity in the studies but no overall difference in perioperative complications between those who quit smoking and those who continued to smoke (OR 0.78, 95% CI, 0.57-1.07). The subset of studies examining pulmonary complications also found no difference (OR 1.18, 95% CI, 0.95-1.46).

Bottom line: Smoking cessation at any time before surgery appears to be safe.

Citation: Myers K, Hajek P, Hinds C, McRobbie H. Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis. Arch Intern Med. 2011;171:983-989.

Hospitalization for Infection Increases Risk of Stroke

Clinical question: Can infection act as a precipitant for acute ischemic stroke?

Background: Little is known about precipitants of acute ischemic stroke. Severe infections have been shown to promote hypercoagulability and platelet activation, and to induce endothelial dysfunction. Authors postulated that infections severe enough to warrant hospitalization might transiently increase the risk for stroke.

Study design: Case-crossover analysis of data from a multicenter prospective cohort (Cardiovascular Health Study).

Setting: Medicare patients in four communities.

Synopsis: During a median follow-up of 12.2 years, 669 strokes occurred in 5,639 study participants. Hospitalization for infection within 14 days was associated with increased risk of stroke (OR 8.0, 95% CI, 1.6-77.3), and the risk remained elevated for hospitalizations within 90 days (OR 3.4, 95% CI, 1.8-6.5). The findings remained significant after adjusting for comorbidities, including age, sex, race, smoking, and diabetes. The number of patients hospitalized for infection before stroke was small—eight within 14 days, and 29 within 90 days.

Bottom line: Infection severe enough to require hospitalization may act as a trigger for acute ischemic stroke.

Citation: Elkind MS, Carty CL, O’Meara ES, et al. Hospitalization for infection and risk of acute ischemic stroke: the Cardiovascular Health Study. Stroke. 2011;42:1851-1856.

Longer Duration of Perioperative Antibiotics May Be Beneficial after Cardiac Surgery

Clinical question: Is antibiotic prophylaxis for 24 or more hours better than shorter duration of treatment after cardiac surgery?

Background: Sternal surgical site infections are a serious complication of cardiac surgery. The optimal duration of perioperative antibiotic prophylaxis is not known, with recommendations ranging from a single dose to 72 hours. The Society of Thoracic Surgeons’ recommendation for 24 to 72 hours of prophylaxis is not based on a systematic review and meta-analysis.

Study design: Systematic review and meta-analysis.

Setting: Adult patients undergoing open-heart surgery who received perioperative antibiotic prophylaxis.

Synopsis: Authors identified 12 trials encompassing 7,893 patients. Compared with prophylaxis of ≥24 hours, prophylaxis of <24 hours was associated with a higher risk of sternal surgical site infections (RR 1.38, 95% CI, 1.13-1.69) and deep infections (RR 1.68, 95% CI, 1.12-2.53). There was no difference in mortality, other infections, or adverse events. Most studies had methodological limitations with a high risk for bias.

Bottom line: Perioperative antibiotic prophylaxis of ≥24 hours reduces sternal surgical infections.

Citation: Mertz D, Johnstone J, Loeb M. Does duration of perioperative antibiotic prophylaxis matter in cardiac surgery? A systematic review and meta-analysis. Ann Surg. 2011;254:48-54.

Stroke Unit Care Combined with Early Supported Discharge Improves Outcomes

Clinical question: Does early supported discharge (ESD) improve outcomes more than conventional follow-up in stroke patients?

Background: ESD is a mobile team that coordinates follow-up and rehabilitation. Previous studies have shown it to be beneficial in patients with mild to moderate disability at one year, but long-term effects of ESD are not known.

Study design: Randomized controlled trial.

Setting: Single center in Norway.

Synopsis: Stroke-unit patients were recruited and received standard care or ESD after discharge. All 320 patients received standard acute care. The proportion of patients with modified Rankin Score (mRS) of ≤2 was not significantly different in the two groups but identified a trend toward improvement in the intervention group (38% vs. 30%, P=0.106). More patients receiving conventional follow-up died or were institutionalized (P=0.032) but mortality rates at five years were similar (ESD 46% vs. 51%). Secondary outcomes (Scandinavian Stroke Scale, Barthel Index, Frenchay Activity Index, and Mini Mental Status Examination) were not statistically different. Predictors of good outcome in the ESD group included young age, low mRS, and living with others.

This study recruited patients from 1995 to 1997 and followed the patients for five years. Limitations to the applicability include advances in stroke rehabilitation in the last 10 years. The cost of a mobile multidisciplinary team consisting of a physiotherapist, occupational therapist, nurse, and part-time physician was not discussed and may limit the availability to many patients.

Bottom line: Early supported discharge may increase the proportion of patients living at home five years after stroke.

Citation: Fjaertoft H, Rohweder G, Indredavik B. Stroke unit care combined with early supported discharge improves 5-year outcome: a randomized controlled trial. Stroke. 2011;42:1707-1711.

Criteria May Help Identify Patients at Risk for Infective Endocarditis

Clinical question: Which patients with Staphylococcus aureus bacteremia benefit the most from transesophageal echocardiography?

Background: Infective endocarditis is a serious complication of S. aureus bacteremia (SAB), occurring in 5% to 17% of patients with documented SAB. It has been recommended to perform transesophageal echocardiography (TEE) in all patients with SAB. Large variation exists in rates of TEE, and identifying patients at low risk for endocarditis may help with more appropriate utilization of this test.

Study design: Retrospective cohort analysis.

Setting: Two university-based German tertiary hospitals (INSTINCT cohort) and one North American university-based hospital from October 1994 to December 2009 (SABG cohort).

Synopsis: A total of 736 cases of nosocomial SAB were analyzed. Age, source of infection, and 30-day and 90-day case fatality rates were similar between the two cohorts. Patients were followed during the index hospitalization and for three months after discharge.

Patients with infective endocarditis were more likely to have prolonged bacteremia; a permanent intracardiac device, such as a pacemaker or a heart valve; be recipients of hemodialysis; and have osteomyelitis. Of the 83 patients who did not fulfill any of the prediction criteria, no cases of infective endocarditis were found.

Bottom line: A set of simple criteria may help identify patients with nosocomial SAB who are at risk for infective endocarditis. The subset of patients who do not meet any of these criteria may not need diagnostic evaluation with TEE.

Citation: Kaasch, AJ, Fowler VG Jr., Rieg S, et al. Use of a simple criteria set for guiding echocardiography in nosocomial Staphylococcus aureus bacteremia. Clin Infect Dis. 2011;53:1-9.

Case

A 68-year-old male with a history of Alzheimer’s dementia and incontinence presents with failure to thrive. A Foley catheter is placed due to the patient’s incontinence and fall risk. Three days after admission while awaiting placement in a skilled nursing facility (SNF), he develops a urinary tract infection (UTI) complicated by delirium delaying his transfer to the SNF. What could have been done to prevent this complication?

Overview

It has been 50 years since Beeson, et al., recognized the potential harms stemming from urethral catheterization and penned an editorial to the American Journal of Medicine titled “The case against the catheter.”1

click for large version

Since then, there has been considerable exploration of ways to limit urethral catheterization and ultimately decrease catheter-associated urinary tract infections (CAUTIs). Unfortunately, little progress has been made; indwelling urinary catheters remain ubiquitous in hospitals and CAUTIs remain the most common hospital-acquired infection in the United States.2 Given the emphasis on the quality and costs of healthcare, it is an opportune time to revisit catheter management and use as a way to combat the clinical and economic consequences of CAUTIs.

Clinicians may be lulled into thinking the clinical impact of CAUTI is less than that of other nosocomial infections. However, beyond the obvious patient harm from UTIs, associated bacteremia, and even death, the public health implications of CAUTI cannot be denied. Urinary tract infections constitute 40% of all nosocomial infections; accounting for an estimated 1 million cases annually.3 Further, 80% of all UTIs are associated with indwelling catheter use.

On average, nosocomial UTI necessitates one extra hospital day per patient, or approximately one million excess hospital days per year.4 Pooled cost analysis shows that UTIs consume an additional $400-$1,700 per event, or an estimated $425 million per year in the United States.5,6 Clearly, we cannot wait another 50 years to address this problem.

Review of the Data

Catheter duration as a risk factor for CAUTI: The indwelling catheter creates a portal of entry into a usually sterile body cavity and provides a surface on which microorganisms can colonize. At a finite rate of colonization—the incidence of bacteriuria is 3% to 10% per catheter day—the duration of urinary catheterization becomes the strongest predictor of catheter-associated bacteriuria.7 Even in relatively short-term catheter use of two to 10 days, the pooled cumulative incidence of developing bacteriuria is 26%.

Given the magnitude of these numbers, it should be no surprise that after one month of catheterization, bacteriuria develops in almost all patients. Twenty-four percent of patients with bacteriuria develop symptomatic UTIs with close to 5% suffering bacteremia. Consequently, nosocomial UTIs cause 15% of all hospital-acquired bacteremia.

Optimal catheter management: The easiest and most effective means to prevent CAUTI is to limit the use of urinary catheters to clearly identified medical indications (see Table 1, above). However, as simple as this prevention practice may sound, studies have demonstrated that as many as 20% of patients have indwelling catheters initially placed for unjustified or even unknown medical indications.8 Additionally, continued catheter use is inappropriate in one-third to one-half of all catheter days.9 These data confirm misuse and overuse of indwelling urinary catheters in the hospital setting is common.

click for large version

In 1981, the Centers for Disease Control and Prevention (CDC) recognized the importance of addressing this situation and published a guideline to aid prevention of CAUTIs.10 The CDC urged the limitation of catheter use to a carefully selected patient population. Furthermore, the report strongly stressed the importance of catheter removal as soon as possible and advised against the use of catheters solely for the convenience of healthcare workers.

Evidence-based techniques for insertion and catheter care also were outlined in the guideline (see Table 2, p. 31). However, these recommendations have been poorly implemented, likely due to the competing priorities of providers and the difficulty operationalizing the guidelines. Additionally, evidence from the intervening 25 years has not yet been incorporated into the guideline, although a revision currently is underway.

Until that revision is complete, the Joanna Briggs Institute guideline published in 2001 addresses some of the same management techniques and incorporates newer evidence.11 Of note, practices that have been discredited due to contradictory evidence include aggressive meatal cleaning, bladder irrigation, and the application of antimicrobial agents in the drainage bag.12

Strategies to reduce unnecessary catheter days: One of the remediable reasons for catheter misuse lies in the fact physicians often are unaware of the presence of an indwelling catheter in their hospitalized patients.

Saint, et al., showed physicians were unaware of catheterization in 28% of their patients and that attending physicians were less conscious of a patient’s catheter status than residents, interns, or medical students.13 Further, the “forgotten” catheters were more likely to be unnecessary than those remembered by the healthcare team.

This information has prompted the use of various computer-based and multidisciplinary feedback protocols to readdress and re-evaluate the need for continued catheterization in a patient. For example, a study at the VAMC Puget Sound demonstrated that having a computerized order protocol for urinary catheters significantly increased the rate of documentation as well as decreased the duration of catheterization by an average of three days.14

Similar interventions to encourage early catheter removal have included daily reminders from nursing staff, allowing a nurse to discontinue catheter use independent of a physician’s order, and feedback in which nursing staff is educated about the incidence of UTI.15-17 All these relatively simple interventions showed significant improvement in the catheter removal rate and incidence of CAUTIs as well as documented cost savings.

Alternatives to indwelling catheters: In addition to efforts to decrease catheter days, alternatives to the indwelling catheters also should be explored. One such alternative method is intermittent catheterization.

Several studies in postoperative patients with hip fractures have demonstrated that the development of UTI is lower with intermittent catheterization when compared with indwelling catheterization.18 Nevertheless, since the risk of bacteriuria is 1% to 3% per episode of catheterization, after a few weeks the majority of patients will have bacteriuria. However, as the bulk of this bacteriuria often is asymptomatic, intermittent catheterization may still be an improvement. This is particularly true in postoperative patients undergoing rehabilitation and those patients only requiring catheterization for a limited number of days.

More recent studies have evaluated the use of bedside bladder ultrasound in an attempt to determine when intermittent catheterization is needed and thereby limit its use compared with standard timed catheterization. Frederickson, et al., demonstrated that this intervention resulted in significantly fewer catheterizations in surgical patients, thus delaying or avoiding the need for catheterization in 81% of the cases.19 Given this drastic improvement, it is no surprise bladder ultrasound use reduced the rates of UTI.20

External condom catheters present another alternative to indwelling catheter use but the outcomes data is conflicting. While the risk of bacteriuria is approximately 12% per month, this rate becomes increasingly higher with frequent manipulation of the condom catheter. 21,22

Two parallel cohort studies in a VA nursing home showed the incidence of symptomatic UTI to be 2.5 times greater in men with an indwelling catheter than those with a condom catheter.23 On the other hand, a cross-sectional Danish study reported higher rates of UTI with external condom catheters than urethral catheters in hospitalized patients.24 Complications from condom catheters include phimosis and local skin maceration, necessitating meticulous care with the use of these devices. Although the data surrounding external catheterization is somewhat contradictory, this device warrants consideration in incontinent males without urinary tract obstruction.

click for large version

There are several other alternatives to urethral catheterization (see Table 3, p. 31), many of which have excellent face validity even in the absence of rigorous evidence.

Antimicrobial catheters: The development of antimicrobial urinary catheters, including silver-alloy and nitrofurazone-coated catheters, has been greeted with much excitement, however, the jury is still out about their best use. A 2006 systematic literature review reported that in comparison to standard catheters, antimicrobial catheters can delay or even prevent the development of bacteriuria with short-term usage.25

However, not all antimicrobial catheters are equally effective; assorted studies lack data about clinically relevant endpoints such as prevention of symptomatic UTI, bloodstream infection or death.26, 27 In addition, there are no good trials comparing nitrofurazone to silver-alloy catheters. Therefore, the level of excitement surrounding antimicrobial catheters—particularly silver-alloy catheters—must be tempered by the additional costs incurred by their use.

To date, the cost-effectiveness of antimicrobial catheters has not been demonstrated. Although additional research in this topic is still needed, some experts currently recommend the consideration of silver-alloy catheters in patients at the highest risk for developing serious consequences from UTIs.

Efforts to reduce CAUTI: In response to significant public interest in hospital-acquired infections including CAUTI, the federal government and many state governments are beginning to demand change. In August 2007, the Centers for Medicare and Medicaid Services instituted a mandate making hospitals financially responsible for selected preventable hospital-acquired harms, including CAUTIs.28 In addition, beginning with Pennsylvania in 2006, several states have mandated public reporting of hospital-acquired infections.29

Given the available information about CAUTI prevalence, risks, and preventive techniques, it is surprising the majority of hospitals in the United States have not taken appropriate measures to limit indwelling catheter use. A recent study by Saint, et al., demonstrated the startling fact that only a minority of hospitals monitor the use of urethral catheters in their patients.30

Among study hospitals, there was no widely used technique to prevent CAUTI including evidence-based practices such as daily catheter reminders. The results of this investigation illustrate the urgent need for a national strategy to reduce CAUTI. Until that time, however, hospital-based physicians must take the lead to champion collaborative efforts, to promote evidence-based catheter use.

Back to the Case

As incontinence and fall risk are not medically appropriate indications for a urethral catheter, a Foley catheter should not have been utilized. Alternatives to indwelling catheterization in this patient would include a bedside commode with nursing assistance, a timed voiding program, intermittent catheterization with or without bladder ultrasound, incontinence pads, or a condom catheter.

Attentiveness to the appropriate medical indications for catheter use, familiarity with catheter alternatives, and recognition of the clinical and economic impact of CAUTI may have prevented this patient’s UTI-induced delirium and facilitated his early transfer to SNF. TH

Dr. Wald is a getriatric hospitalist and assistant professor of medicine at the University of Colorado, Denver. Dr. Furfari is a hospital medicine fellow at the University of Colorado Denver.

References

1. Beeson PB. The case against the catheter. Am J Med. 1958;24:1-3.
2. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control. 2000;28:68-75.
3. Sedor J, Mulholland SG. Hospital-acquired UTIs associated with the indwelling catheter. Urol Clin North Am. 1999;26:821-828.
4. Foxman B. Epidemiology of UTI: Incidence, morbidity and economic costs. Am J Med. 2002;113(1A):5S-13S.
5. Tambyah PA, Knasinski V, Maki D. The direct costs of nosocomial catheter-associated UTI in the era of managed care. Infect Control Hosp Epidemiol. 2002;23:27-31.
6. Jarvis, WR. Selected aspects of socioeconomic impact of nosocomial infections. Infect Control Hosp Epidemiol. 1996;17:552-557.
7. Warren JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am. 1997;11:609-622.
8. Jain P, Parada JP, David A, Smith L. Overuse of the indwelling urinary catheter in hospitalized medical patients. Arch Internal Med. 1995;155:1425-1429.
9. Hartstein AI, Garber SB, Ward TT, Jones SR, Morthland VH. Nosocomial urinary tract infection: a prospective evaluation of 108 catheterized patients. Infect Control. 1981;2:380-386.
10. Wong E. Guideline for prevention of catheter-associated urinary tract infections. Center for Disease Control and Prevention 1981. Available at: www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html . Accessed May 8, 2008.
11. Joanna Briggs Institute. Management of short term indwelling urethral catheters to prevent urinary tract infections. 2000;4(1):ISSN 1329-1874.
12. Burke JP, Garibaldi RA, Britt MR, Jacobson JA, Conti M, Alling DW. Prevention of catheter-associated urinary tract infections. Am J Med. 1981;70:655-658.
13. Saint S, Wiese J, Amory JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109:476-480.
14. Cornia PB, Amory JK, Fraser S, Saint S, Lipsky BA. Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients. Am J Med. 2003;114:404-406.
15. Huang WC, Wann SR, Lin SL, et al. Catheter-associated urinary tract infections in intensive care units can be reduced by prompting physicians to remove unnecessary catheters. Infect Control Hosp Epidemiol. 2004;25(11):974-978.
16. Topal J, Conklin S, Camp K, Morris TB, Herbert P. Prevention of nosocomial catheter-associated urinary tract infections through computerized feedback to physicians and a nurse-directed protocol. Am J Med Qual. 2005;20(3):121-126.
17. Goetz AM, Kedzuf S, Wagener M, Muder R. Feedback to nursing staff as an intervention to reduce catheter-associated urinary tract infections. Am J Infect Control. 1999;27(5):402-404.
18. Johansson I, Athlin E, Frykholm L, Bolinder H, Larsson G. Intermittent versus indwelling catheters for older patients with hip fractures. J Clin Nurs. 2002;11:651-656.
19. Frederickson M, Neitzel JJ, Miller EH, Reuter S, Graner T, Heller J. The implementation of bedside bladder ultrasound technology: Effects of patient and cost postoperative outcomes in tertiary care. Orthop Nurs. 2000;19(3):79-87.
20. Slappendel R, Weber EWG. Non-invasive measurement of bladder volume as an indication for bladder catheterization after orthopedic surgery and its effect on urinary tract infections. Eur J Anesthesiol. 1999;16:503-506.
21. Hirsh D, Fainstein V, Musher DM. Do condom catheter collecting systems cause urinary tract infections? JAMA. 1979;242:340-341.
22. Wong ES. Guideline for prevention of catheter-associated urinary tract infections. Am J Infect Control. 1983;11:28-36.
23. Saint S, Lipsky BA. Preventing catheter-related bacteriuria. Should We? Can We? How? Arch Internal Med. 1999;159:800-808.
24. Zimakoff J, Stickler DJ, Pontoppidan B, Larsen SO. Bladder management and urinary tract infection in Danish hospitals, nursing homes and home care: A national prevalence study. Infect Control Hosp Epidemiol. 1996;17(4):215-221.
25. Johnson JR, Kuskowski MA, Wilt TJ. Systematic Review: Antimicrobial urinary catheters to prevent catheter-associated urinary tract infections in hospitalized patients. Ann Internal Med. 2006;144(2):116-126.
26. Saint S, Elmore JG, Sullivan SD, Emerson SS, Koepsell TD. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infections; a meta-analysis. Am J Med. 1998;105(3):236-241.
27. Bronahan J, Jull A, Tracy C. Cochrane incontinence group. Types of urethral catheters for management of short-term voiding problems in hospitalized adults. Cochrane Database Syst Rev. 2004;1:CD004013.
28. Wald HL, Kramer AM. Nonpayment for harms resulting from medical care. JAMA. 2007;298(23):2782-2784.
29. Goldstein J. Hospital infections’ cost tallied. The Philadelphia Inquirer. Nov. 15, 2006.
30. Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital-acquired urinary tract infection in the United States: A national study. Clin Infect Dis. 2008;46(2):243-250.

Case

A 68-year-old male with a history of Alzheimer’s dementia and incontinence presents with failure to thrive. A Foley catheter is placed due to the patient’s incontinence and fall risk. Three days after admission while awaiting placement in a skilled nursing facility (SNF), he develops a urinary tract infection (UTI) complicated by delirium delaying his transfer to the SNF. What could have been done to prevent this complication?

Overview

It has been 50 years since Beeson, et al., recognized the potential harms stemming from urethral catheterization and penned an editorial to the American Journal of Medicine titled “The case against the catheter.”1

click for large version

Since then, there has been considerable exploration of ways to limit urethral catheterization and ultimately decrease catheter-associated urinary tract infections (CAUTIs). Unfortunately, little progress has been made; indwelling urinary catheters remain ubiquitous in hospitals and CAUTIs remain the most common hospital-acquired infection in the United States.2 Given the emphasis on the quality and costs of healthcare, it is an opportune time to revisit catheter management and use as a way to combat the clinical and economic consequences of CAUTIs.

Clinicians may be lulled into thinking the clinical impact of CAUTI is less than that of other nosocomial infections. However, beyond the obvious patient harm from UTIs, associated bacteremia, and even death, the public health implications of CAUTI cannot be denied. Urinary tract infections constitute 40% of all nosocomial infections; accounting for an estimated 1 million cases annually.3 Further, 80% of all UTIs are associated with indwelling catheter use.

On average, nosocomial UTI necessitates one extra hospital day per patient, or approximately one million excess hospital days per year.4 Pooled cost analysis shows that UTIs consume an additional $400-$1,700 per event, or an estimated $425 million per year in the United States.5,6 Clearly, we cannot wait another 50 years to address this problem.

Review of the Data

Catheter duration as a risk factor for CAUTI: The indwelling catheter creates a portal of entry into a usually sterile body cavity and provides a surface on which microorganisms can colonize. At a finite rate of colonization—the incidence of bacteriuria is 3% to 10% per catheter day—the duration of urinary catheterization becomes the strongest predictor of catheter-associated bacteriuria.7 Even in relatively short-term catheter use of two to 10 days, the pooled cumulative incidence of developing bacteriuria is 26%.

Given the magnitude of these numbers, it should be no surprise that after one month of catheterization, bacteriuria develops in almost all patients. Twenty-four percent of patients with bacteriuria develop symptomatic UTIs with close to 5% suffering bacteremia. Consequently, nosocomial UTIs cause 15% of all hospital-acquired bacteremia.

Optimal catheter management: The easiest and most effective means to prevent CAUTI is to limit the use of urinary catheters to clearly identified medical indications (see Table 1, above). However, as simple as this prevention practice may sound, studies have demonstrated that as many as 20% of patients have indwelling catheters initially placed for unjustified or even unknown medical indications.8 Additionally, continued catheter use is inappropriate in one-third to one-half of all catheter days.9 These data confirm misuse and overuse of indwelling urinary catheters in the hospital setting is common.

click for large version

In 1981, the Centers for Disease Control and Prevention (CDC) recognized the importance of addressing this situation and published a guideline to aid prevention of CAUTIs.10 The CDC urged the limitation of catheter use to a carefully selected patient population. Furthermore, the report strongly stressed the importance of catheter removal as soon as possible and advised against the use of catheters solely for the convenience of healthcare workers.

Evidence-based techniques for insertion and catheter care also were outlined in the guideline (see Table 2, p. 31). However, these recommendations have been poorly implemented, likely due to the competing priorities of providers and the difficulty operationalizing the guidelines. Additionally, evidence from the intervening 25 years has not yet been incorporated into the guideline, although a revision currently is underway.

Until that revision is complete, the Joanna Briggs Institute guideline published in 2001 addresses some of the same management techniques and incorporates newer evidence.11 Of note, practices that have been discredited due to contradictory evidence include aggressive meatal cleaning, bladder irrigation, and the application of antimicrobial agents in the drainage bag.12

Strategies to reduce unnecessary catheter days: One of the remediable reasons for catheter misuse lies in the fact physicians often are unaware of the presence of an indwelling catheter in their hospitalized patients.

Saint, et al., showed physicians were unaware of catheterization in 28% of their patients and that attending physicians were less conscious of a patient’s catheter status than residents, interns, or medical students.13 Further, the “forgotten” catheters were more likely to be unnecessary than those remembered by the healthcare team.

This information has prompted the use of various computer-based and multidisciplinary feedback protocols to readdress and re-evaluate the need for continued catheterization in a patient. For example, a study at the VAMC Puget Sound demonstrated that having a computerized order protocol for urinary catheters significantly increased the rate of documentation as well as decreased the duration of catheterization by an average of three days.14

Similar interventions to encourage early catheter removal have included daily reminders from nursing staff, allowing a nurse to discontinue catheter use independent of a physician’s order, and feedback in which nursing staff is educated about the incidence of UTI.15-17 All these relatively simple interventions showed significant improvement in the catheter removal rate and incidence of CAUTIs as well as documented cost savings.

Alternatives to indwelling catheters: In addition to efforts to decrease catheter days, alternatives to the indwelling catheters also should be explored. One such alternative method is intermittent catheterization.

Several studies in postoperative patients with hip fractures have demonstrated that the development of UTI is lower with intermittent catheterization when compared with indwelling catheterization.18 Nevertheless, since the risk of bacteriuria is 1% to 3% per episode of catheterization, after a few weeks the majority of patients will have bacteriuria. However, as the bulk of this bacteriuria often is asymptomatic, intermittent catheterization may still be an improvement. This is particularly true in postoperative patients undergoing rehabilitation and those patients only requiring catheterization for a limited number of days.

More recent studies have evaluated the use of bedside bladder ultrasound in an attempt to determine when intermittent catheterization is needed and thereby limit its use compared with standard timed catheterization. Frederickson, et al., demonstrated that this intervention resulted in significantly fewer catheterizations in surgical patients, thus delaying or avoiding the need for catheterization in 81% of the cases.19 Given this drastic improvement, it is no surprise bladder ultrasound use reduced the rates of UTI.20

External condom catheters present another alternative to indwelling catheter use but the outcomes data is conflicting. While the risk of bacteriuria is approximately 12% per month, this rate becomes increasingly higher with frequent manipulation of the condom catheter. 21,22

Two parallel cohort studies in a VA nursing home showed the incidence of symptomatic UTI to be 2.5 times greater in men with an indwelling catheter than those with a condom catheter.23 On the other hand, a cross-sectional Danish study reported higher rates of UTI with external condom catheters than urethral catheters in hospitalized patients.24 Complications from condom catheters include phimosis and local skin maceration, necessitating meticulous care with the use of these devices. Although the data surrounding external catheterization is somewhat contradictory, this device warrants consideration in incontinent males without urinary tract obstruction.

click for large version

There are several other alternatives to urethral catheterization (see Table 3, p. 31), many of which have excellent face validity even in the absence of rigorous evidence.

Antimicrobial catheters: The development of antimicrobial urinary catheters, including silver-alloy and nitrofurazone-coated catheters, has been greeted with much excitement, however, the jury is still out about their best use. A 2006 systematic literature review reported that in comparison to standard catheters, antimicrobial catheters can delay or even prevent the development of bacteriuria with short-term usage.25

However, not all antimicrobial catheters are equally effective; assorted studies lack data about clinically relevant endpoints such as prevention of symptomatic UTI, bloodstream infection or death.26, 27 In addition, there are no good trials comparing nitrofurazone to silver-alloy catheters. Therefore, the level of excitement surrounding antimicrobial catheters—particularly silver-alloy catheters—must be tempered by the additional costs incurred by their use.

To date, the cost-effectiveness of antimicrobial catheters has not been demonstrated. Although additional research in this topic is still needed, some experts currently recommend the consideration of silver-alloy catheters in patients at the highest risk for developing serious consequences from UTIs.

Efforts to reduce CAUTI: In response to significant public interest in hospital-acquired infections including CAUTI, the federal government and many state governments are beginning to demand change. In August 2007, the Centers for Medicare and Medicaid Services instituted a mandate making hospitals financially responsible for selected preventable hospital-acquired harms, including CAUTIs.28 In addition, beginning with Pennsylvania in 2006, several states have mandated public reporting of hospital-acquired infections.29

Given the available information about CAUTI prevalence, risks, and preventive techniques, it is surprising the majority of hospitals in the United States have not taken appropriate measures to limit indwelling catheter use. A recent study by Saint, et al., demonstrated the startling fact that only a minority of hospitals monitor the use of urethral catheters in their patients.30

Among study hospitals, there was no widely used technique to prevent CAUTI including evidence-based practices such as daily catheter reminders. The results of this investigation illustrate the urgent need for a national strategy to reduce CAUTI. Until that time, however, hospital-based physicians must take the lead to champion collaborative efforts, to promote evidence-based catheter use.

Back to the Case

As incontinence and fall risk are not medically appropriate indications for a urethral catheter, a Foley catheter should not have been utilized. Alternatives to indwelling catheterization in this patient would include a bedside commode with nursing assistance, a timed voiding program, intermittent catheterization with or without bladder ultrasound, incontinence pads, or a condom catheter.

Attentiveness to the appropriate medical indications for catheter use, familiarity with catheter alternatives, and recognition of the clinical and economic impact of CAUTI may have prevented this patient’s UTI-induced delirium and facilitated his early transfer to SNF. TH

Dr. Wald is a getriatric hospitalist and assistant professor of medicine at the University of Colorado, Denver. Dr. Furfari is a hospital medicine fellow at the University of Colorado Denver.

References

1. Beeson PB. The case against the catheter. Am J Med. 1958;24:1-3.
2. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control. 2000;28:68-75.
3. Sedor J, Mulholland SG. Hospital-acquired UTIs associated with the indwelling catheter. Urol Clin North Am. 1999;26:821-828.
4. Foxman B. Epidemiology of UTI: Incidence, morbidity and economic costs. Am J Med. 2002;113(1A):5S-13S.
5. Tambyah PA, Knasinski V, Maki D. The direct costs of nosocomial catheter-associated UTI in the era of managed care. Infect Control Hosp Epidemiol. 2002;23:27-31.
6. Jarvis, WR. Selected aspects of socioeconomic impact of nosocomial infections. Infect Control Hosp Epidemiol. 1996;17:552-557.
7. Warren JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am. 1997;11:609-622.
8. Jain P, Parada JP, David A, Smith L. Overuse of the indwelling urinary catheter in hospitalized medical patients. Arch Internal Med. 1995;155:1425-1429.
9. Hartstein AI, Garber SB, Ward TT, Jones SR, Morthland VH. Nosocomial urinary tract infection: a prospective evaluation of 108 catheterized patients. Infect Control. 1981;2:380-386.
10. Wong E. Guideline for prevention of catheter-associated urinary tract infections. Center for Disease Control and Prevention 1981. Available at: www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html . Accessed May 8, 2008.
11. Joanna Briggs Institute. Management of short term indwelling urethral catheters to prevent urinary tract infections. 2000;4(1):ISSN 1329-1874.
12. Burke JP, Garibaldi RA, Britt MR, Jacobson JA, Conti M, Alling DW. Prevention of catheter-associated urinary tract infections. Am J Med. 1981;70:655-658.
13. Saint S, Wiese J, Amory JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109:476-480.
14. Cornia PB, Amory JK, Fraser S, Saint S, Lipsky BA. Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients. Am J Med. 2003;114:404-406.
15. Huang WC, Wann SR, Lin SL, et al. Catheter-associated urinary tract infections in intensive care units can be reduced by prompting physicians to remove unnecessary catheters. Infect Control Hosp Epidemiol. 2004;25(11):974-978.
16. Topal J, Conklin S, Camp K, Morris TB, Herbert P. Prevention of nosocomial catheter-associated urinary tract infections through computerized feedback to physicians and a nurse-directed protocol. Am J Med Qual. 2005;20(3):121-126.
17. Goetz AM, Kedzuf S, Wagener M, Muder R. Feedback to nursing staff as an intervention to reduce catheter-associated urinary tract infections. Am J Infect Control. 1999;27(5):402-404.
18. Johansson I, Athlin E, Frykholm L, Bolinder H, Larsson G. Intermittent versus indwelling catheters for older patients with hip fractures. J Clin Nurs. 2002;11:651-656.
19. Frederickson M, Neitzel JJ, Miller EH, Reuter S, Graner T, Heller J. The implementation of bedside bladder ultrasound technology: Effects of patient and cost postoperative outcomes in tertiary care. Orthop Nurs. 2000;19(3):79-87.
20. Slappendel R, Weber EWG. Non-invasive measurement of bladder volume as an indication for bladder catheterization after orthopedic surgery and its effect on urinary tract infections. Eur J Anesthesiol. 1999;16:503-506.
21. Hirsh D, Fainstein V, Musher DM. Do condom catheter collecting systems cause urinary tract infections? JAMA. 1979;242:340-341.
22. Wong ES. Guideline for prevention of catheter-associated urinary tract infections. Am J Infect Control. 1983;11:28-36.
23. Saint S, Lipsky BA. Preventing catheter-related bacteriuria. Should We? Can We? How? Arch Internal Med. 1999;159:800-808.
24. Zimakoff J, Stickler DJ, Pontoppidan B, Larsen SO. Bladder management and urinary tract infection in Danish hospitals, nursing homes and home care: A national prevalence study. Infect Control Hosp Epidemiol. 1996;17(4):215-221.
25. Johnson JR, Kuskowski MA, Wilt TJ. Systematic Review: Antimicrobial urinary catheters to prevent catheter-associated urinary tract infections in hospitalized patients. Ann Internal Med. 2006;144(2):116-126.
26. Saint S, Elmore JG, Sullivan SD, Emerson SS, Koepsell TD. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infections; a meta-analysis. Am J Med. 1998;105(3):236-241.
27. Bronahan J, Jull A, Tracy C. Cochrane incontinence group. Types of urethral catheters for management of short-term voiding problems in hospitalized adults. Cochrane Database Syst Rev. 2004;1:CD004013.
28. Wald HL, Kramer AM. Nonpayment for harms resulting from medical care. JAMA. 2007;298(23):2782-2784.
29. Goldstein J. Hospital infections’ cost tallied. The Philadelphia Inquirer. Nov. 15, 2006.
30. Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital-acquired urinary tract infection in the United States: A national study. Clin Infect Dis. 2008;46(2):243-250.

Case

A 68-year-old male with a history of Alzheimer’s dementia and incontinence presents with failure to thrive. A Foley catheter is placed due to the patient’s incontinence and fall risk. Three days after admission while awaiting placement in a skilled nursing facility (SNF), he develops a urinary tract infection (UTI) complicated by delirium delaying his transfer to the SNF. What could have been done to prevent this complication?

Overview

It has been 50 years since Beeson, et al., recognized the potential harms stemming from urethral catheterization and penned an editorial to the American Journal of Medicine titled “The case against the catheter.”1

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Since then, there has been considerable exploration of ways to limit urethral catheterization and ultimately decrease catheter-associated urinary tract infections (CAUTIs). Unfortunately, little progress has been made; indwelling urinary catheters remain ubiquitous in hospitals and CAUTIs remain the most common hospital-acquired infection in the United States.2 Given the emphasis on the quality and costs of healthcare, it is an opportune time to revisit catheter management and use as a way to combat the clinical and economic consequences of CAUTIs.

Clinicians may be lulled into thinking the clinical impact of CAUTI is less than that of other nosocomial infections. However, beyond the obvious patient harm from UTIs, associated bacteremia, and even death, the public health implications of CAUTI cannot be denied. Urinary tract infections constitute 40% of all nosocomial infections; accounting for an estimated 1 million cases annually.3 Further, 80% of all UTIs are associated with indwelling catheter use.

On average, nosocomial UTI necessitates one extra hospital day per patient, or approximately one million excess hospital days per year.4 Pooled cost analysis shows that UTIs consume an additional $400-$1,700 per event, or an estimated $425 million per year in the United States.5,6 Clearly, we cannot wait another 50 years to address this problem.

Review of the Data

Catheter duration as a risk factor for CAUTI: The indwelling catheter creates a portal of entry into a usually sterile body cavity and provides a surface on which microorganisms can colonize. At a finite rate of colonization—the incidence of bacteriuria is 3% to 10% per catheter day—the duration of urinary catheterization becomes the strongest predictor of catheter-associated bacteriuria.7 Even in relatively short-term catheter use of two to 10 days, the pooled cumulative incidence of developing bacteriuria is 26%.

Given the magnitude of these numbers, it should be no surprise that after one month of catheterization, bacteriuria develops in almost all patients. Twenty-four percent of patients with bacteriuria develop symptomatic UTIs with close to 5% suffering bacteremia. Consequently, nosocomial UTIs cause 15% of all hospital-acquired bacteremia.

Optimal catheter management: The easiest and most effective means to prevent CAUTI is to limit the use of urinary catheters to clearly identified medical indications (see Table 1, above). However, as simple as this prevention practice may sound, studies have demonstrated that as many as 20% of patients have indwelling catheters initially placed for unjustified or even unknown medical indications.8 Additionally, continued catheter use is inappropriate in one-third to one-half of all catheter days.9 These data confirm misuse and overuse of indwelling urinary catheters in the hospital setting is common.

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In 1981, the Centers for Disease Control and Prevention (CDC) recognized the importance of addressing this situation and published a guideline to aid prevention of CAUTIs.10 The CDC urged the limitation of catheter use to a carefully selected patient population. Furthermore, the report strongly stressed the importance of catheter removal as soon as possible and advised against the use of catheters solely for the convenience of healthcare workers.

Evidence-based techniques for insertion and catheter care also were outlined in the guideline (see Table 2, p. 31). However, these recommendations have been poorly implemented, likely due to the competing priorities of providers and the difficulty operationalizing the guidelines. Additionally, evidence from the intervening 25 years has not yet been incorporated into the guideline, although a revision currently is underway.

Until that revision is complete, the Joanna Briggs Institute guideline published in 2001 addresses some of the same management techniques and incorporates newer evidence.11 Of note, practices that have been discredited due to contradictory evidence include aggressive meatal cleaning, bladder irrigation, and the application of antimicrobial agents in the drainage bag.12

Strategies to reduce unnecessary catheter days: One of the remediable reasons for catheter misuse lies in the fact physicians often are unaware of the presence of an indwelling catheter in their hospitalized patients.

Saint, et al., showed physicians were unaware of catheterization in 28% of their patients and that attending physicians were less conscious of a patient’s catheter status than residents, interns, or medical students.13 Further, the “forgotten” catheters were more likely to be unnecessary than those remembered by the healthcare team.

This information has prompted the use of various computer-based and multidisciplinary feedback protocols to readdress and re-evaluate the need for continued catheterization in a patient. For example, a study at the VAMC Puget Sound demonstrated that having a computerized order protocol for urinary catheters significantly increased the rate of documentation as well as decreased the duration of catheterization by an average of three days.14

Similar interventions to encourage early catheter removal have included daily reminders from nursing staff, allowing a nurse to discontinue catheter use independent of a physician’s order, and feedback in which nursing staff is educated about the incidence of UTI.15-17 All these relatively simple interventions showed significant improvement in the catheter removal rate and incidence of CAUTIs as well as documented cost savings.

Alternatives to indwelling catheters: In addition to efforts to decrease catheter days, alternatives to the indwelling catheters also should be explored. One such alternative method is intermittent catheterization.

Several studies in postoperative patients with hip fractures have demonstrated that the development of UTI is lower with intermittent catheterization when compared with indwelling catheterization.18 Nevertheless, since the risk of bacteriuria is 1% to 3% per episode of catheterization, after a few weeks the majority of patients will have bacteriuria. However, as the bulk of this bacteriuria often is asymptomatic, intermittent catheterization may still be an improvement. This is particularly true in postoperative patients undergoing rehabilitation and those patients only requiring catheterization for a limited number of days.

More recent studies have evaluated the use of bedside bladder ultrasound in an attempt to determine when intermittent catheterization is needed and thereby limit its use compared with standard timed catheterization. Frederickson, et al., demonstrated that this intervention resulted in significantly fewer catheterizations in surgical patients, thus delaying or avoiding the need for catheterization in 81% of the cases.19 Given this drastic improvement, it is no surprise bladder ultrasound use reduced the rates of UTI.20

External condom catheters present another alternative to indwelling catheter use but the outcomes data is conflicting. While the risk of bacteriuria is approximately 12% per month, this rate becomes increasingly higher with frequent manipulation of the condom catheter. 21,22

Two parallel cohort studies in a VA nursing home showed the incidence of symptomatic UTI to be 2.5 times greater in men with an indwelling catheter than those with a condom catheter.23 On the other hand, a cross-sectional Danish study reported higher rates of UTI with external condom catheters than urethral catheters in hospitalized patients.24 Complications from condom catheters include phimosis and local skin maceration, necessitating meticulous care with the use of these devices. Although the data surrounding external catheterization is somewhat contradictory, this device warrants consideration in incontinent males without urinary tract obstruction.

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There are several other alternatives to urethral catheterization (see Table 3, p. 31), many of which have excellent face validity even in the absence of rigorous evidence.

Antimicrobial catheters: The development of antimicrobial urinary catheters, including silver-alloy and nitrofurazone-coated catheters, has been greeted with much excitement, however, the jury is still out about their best use. A 2006 systematic literature review reported that in comparison to standard catheters, antimicrobial catheters can delay or even prevent the development of bacteriuria with short-term usage.25

However, not all antimicrobial catheters are equally effective; assorted studies lack data about clinically relevant endpoints such as prevention of symptomatic UTI, bloodstream infection or death.26, 27 In addition, there are no good trials comparing nitrofurazone to silver-alloy catheters. Therefore, the level of excitement surrounding antimicrobial catheters—particularly silver-alloy catheters—must be tempered by the additional costs incurred by their use.

To date, the cost-effectiveness of antimicrobial catheters has not been demonstrated. Although additional research in this topic is still needed, some experts currently recommend the consideration of silver-alloy catheters in patients at the highest risk for developing serious consequences from UTIs.

Efforts to reduce CAUTI: In response to significant public interest in hospital-acquired infections including CAUTI, the federal government and many state governments are beginning to demand change. In August 2007, the Centers for Medicare and Medicaid Services instituted a mandate making hospitals financially responsible for selected preventable hospital-acquired harms, including CAUTIs.28 In addition, beginning with Pennsylvania in 2006, several states have mandated public reporting of hospital-acquired infections.29

Given the available information about CAUTI prevalence, risks, and preventive techniques, it is surprising the majority of hospitals in the United States have not taken appropriate measures to limit indwelling catheter use. A recent study by Saint, et al., demonstrated the startling fact that only a minority of hospitals monitor the use of urethral catheters in their patients.30

Among study hospitals, there was no widely used technique to prevent CAUTI including evidence-based practices such as daily catheter reminders. The results of this investigation illustrate the urgent need for a national strategy to reduce CAUTI. Until that time, however, hospital-based physicians must take the lead to champion collaborative efforts, to promote evidence-based catheter use.

Back to the Case

As incontinence and fall risk are not medically appropriate indications for a urethral catheter, a Foley catheter should not have been utilized. Alternatives to indwelling catheterization in this patient would include a bedside commode with nursing assistance, a timed voiding program, intermittent catheterization with or without bladder ultrasound, incontinence pads, or a condom catheter.

Attentiveness to the appropriate medical indications for catheter use, familiarity with catheter alternatives, and recognition of the clinical and economic impact of CAUTI may have prevented this patient’s UTI-induced delirium and facilitated his early transfer to SNF. TH

Dr. Wald is a getriatric hospitalist and assistant professor of medicine at the University of Colorado, Denver. Dr. Furfari is a hospital medicine fellow at the University of Colorado Denver.

References

1. Beeson PB. The case against the catheter. Am J Med. 1958;24:1-3.
2. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control. 2000;28:68-75.
3. Sedor J, Mulholland SG. Hospital-acquired UTIs associated with the indwelling catheter. Urol Clin North Am. 1999;26:821-828.
4. Foxman B. Epidemiology of UTI: Incidence, morbidity and economic costs. Am J Med. 2002;113(1A):5S-13S.
5. Tambyah PA, Knasinski V, Maki D. The direct costs of nosocomial catheter-associated UTI in the era of managed care. Infect Control Hosp Epidemiol. 2002;23:27-31.
6. Jarvis, WR. Selected aspects of socioeconomic impact of nosocomial infections. Infect Control Hosp Epidemiol. 1996;17:552-557.
7. Warren JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am. 1997;11:609-622.
8. Jain P, Parada JP, David A, Smith L. Overuse of the indwelling urinary catheter in hospitalized medical patients. Arch Internal Med. 1995;155:1425-1429.
9. Hartstein AI, Garber SB, Ward TT, Jones SR, Morthland VH. Nosocomial urinary tract infection: a prospective evaluation of 108 catheterized patients. Infect Control. 1981;2:380-386.
10. Wong E. Guideline for prevention of catheter-associated urinary tract infections. Center for Disease Control and Prevention 1981. Available at: www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html . Accessed May 8, 2008.
11. Joanna Briggs Institute. Management of short term indwelling urethral catheters to prevent urinary tract infections. 2000;4(1):ISSN 1329-1874.
12. Burke JP, Garibaldi RA, Britt MR, Jacobson JA, Conti M, Alling DW. Prevention of catheter-associated urinary tract infections. Am J Med. 1981;70:655-658.
13. Saint S, Wiese J, Amory JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109:476-480.
14. Cornia PB, Amory JK, Fraser S, Saint S, Lipsky BA. Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients. Am J Med. 2003;114:404-406.
15. Huang WC, Wann SR, Lin SL, et al. Catheter-associated urinary tract infections in intensive care units can be reduced by prompting physicians to remove unnecessary catheters. Infect Control Hosp Epidemiol. 2004;25(11):974-978.
16. Topal J, Conklin S, Camp K, Morris TB, Herbert P. Prevention of nosocomial catheter-associated urinary tract infections through computerized feedback to physicians and a nurse-directed protocol. Am J Med Qual. 2005;20(3):121-126.
17. Goetz AM, Kedzuf S, Wagener M, Muder R. Feedback to nursing staff as an intervention to reduce catheter-associated urinary tract infections. Am J Infect Control. 1999;27(5):402-404.
18. Johansson I, Athlin E, Frykholm L, Bolinder H, Larsson G. Intermittent versus indwelling catheters for older patients with hip fractures. J Clin Nurs. 2002;11:651-656.
19. Frederickson M, Neitzel JJ, Miller EH, Reuter S, Graner T, Heller J. The implementation of bedside bladder ultrasound technology: Effects of patient and cost postoperative outcomes in tertiary care. Orthop Nurs. 2000;19(3):79-87.
20. Slappendel R, Weber EWG. Non-invasive measurement of bladder volume as an indication for bladder catheterization after orthopedic surgery and its effect on urinary tract infections. Eur J Anesthesiol. 1999;16:503-506.
21. Hirsh D, Fainstein V, Musher DM. Do condom catheter collecting systems cause urinary tract infections? JAMA. 1979;242:340-341.
22. Wong ES. Guideline for prevention of catheter-associated urinary tract infections. Am J Infect Control. 1983;11:28-36.
23. Saint S, Lipsky BA. Preventing catheter-related bacteriuria. Should We? Can We? How? Arch Internal Med. 1999;159:800-808.
24. Zimakoff J, Stickler DJ, Pontoppidan B, Larsen SO. Bladder management and urinary tract infection in Danish hospitals, nursing homes and home care: A national prevalence study. Infect Control Hosp Epidemiol. 1996;17(4):215-221.
25. Johnson JR, Kuskowski MA, Wilt TJ. Systematic Review: Antimicrobial urinary catheters to prevent catheter-associated urinary tract infections in hospitalized patients. Ann Internal Med. 2006;144(2):116-126.
26. Saint S, Elmore JG, Sullivan SD, Emerson SS, Koepsell TD. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infections; a meta-analysis. Am J Med. 1998;105(3):236-241.
27. Bronahan J, Jull A, Tracy C. Cochrane incontinence group. Types of urethral catheters for management of short-term voiding problems in hospitalized adults. Cochrane Database Syst Rev. 2004;1:CD004013.
28. Wald HL, Kramer AM. Nonpayment for harms resulting from medical care. JAMA. 2007;298(23):2782-2784.
29. Goldstein J. Hospital infections’ cost tallied. The Philadelphia Inquirer. Nov. 15, 2006.
30. Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital-acquired urinary tract infection in the United States: A national study. Clin Infect Dis. 2008;46(2):243-250.