Inpatient Notes
—Claire M. Rickard, RN, PhD, and Nicole M. Marsh, RN, MAppPrac (HealthRes)
The peripheral intravenous catheter is one of the most important and prevalent medical devices in the hospital, so why have quality improvement efforts neglected this device? The authors of this issue's Inpatient Notes argue that it's time to improve this staple of inpatient care.
Highlights of Recent Articles From Annals of Internal Medicine
Ann Intern Med. 2017;167:ITC66-ITC80. doi:AITC201711070
In this narrative review article, the authors provide an overview of the diagnosis, prevention, and treatment of acute kidney injury (AKI).
Key points for hospitalists include:
Acute kidney injury occurs in about 20% of hospitalized patients, most commonly in older patients and those with underlying chronic kidney disease. About 10% of hospitalized patients with AKI require renal replacement therapy.
There are many causes of AKI in hospitalized patients. Reduced renal perfusion (e.g., volume depletion, sepsis, and heart or liver failure) is a common cause of AKI in patients presenting for hospital admission. Acute tubular necrosis is the most common hospital-acquired cause.
Medications can lead to AKI by causing acute tubular necrosis (e.g., radiocontrast, aminoglycosides, vancomycin, amphotericin B, cisplatin, carboplatin, iphosphamide), interstitial nephritis (e.g., β-lactams, sulfonamides), crystal nephropathy (e.g., methotrexate, acyclovir), or other insults (e.g., nonsteroidal anti-inflammatory drugs, angiotensin–converting enzyme inhibitors, angiotensin–receptor blockers, calcineurin inhibitors).
Although loop diuretics can increase urine output in some cases of AKI, they do not seem to decrease mortality, the need for renal replacement therapy, or the time to renal recovery.
Ann Intern Med. 2017;167:725-735. Published 14 November 2017. doi:10.7326/M17-1811
This systematic review (an update to a 2005 Agency for Healthcare Research and Quality review) analyzed 6 observational studies of screening for post–acute coronary syndrome (ACS) depression, and 4 randomized controlled trials (RCTs) for treatment of post-ACS depression. The review shows that available depression screening tools exhibit acceptable sensitivity, specificity, and negative predictive value in this population, although positive predictive values are low. Three of 4 studies of treatment showed a decrease in depressive symptoms with medications, psychotherapy, or both, although the clinical significance of the improvements was thought to be relatively minor.
Key points for hospitalists include:
Major depressive disorder is common after ACS, affecting up to 20% of patients. An even greater percentage of these patients have less-severe depression. Hospitalists should be on the lookout for this disorder.
Existing depression screening tools seem to function adequately in this population, and treatment methods (such as medication and psychotherapy) do have a favorable effect on psychosocial outcomes. There is no evidence that these interventions improve cardiovascular outcomes.
There is no evidence that screening for depression in this population improves outcomes, and guidelines differ on whether they do or do not recommend it.
Ann Intern Med. 2017;167:698-705. Published 3 October 2017. doi:10.7326/M16-2726
In this prospective cohort study, investigators analyzed clinical variables and 30-day mortality in patients presenting to 34 Spanish emergency departments with acute heart failure in order to derive (4867 patients) and validate (3229 patients) a risk score to predict 30-day mortality. The resulting model used 13 clinical variables (including age, vital signs, laboratory values, and the Barthel index score) to stratify risk for 30-day mortality and achieved good discrimination (a mortality rate of <2% with scores in the lowest 2 quintiles vs. a mortality rate of 45% for those with scores in the highest decile). The c-statistic in the validation group was 0.828, indicating good model performance.
Key points for hospitalists include:
The authors suggest that clinical decisions in patients with acute heart failure (e.g., deciding which patients require hospital admission) are often made without any formal risk assessment, resulting in an inability to match the intensity of care to the risk for mortality.
The model described in this paper appears to have good discrimination of risk in this population and may allow clinicians to better estimate mortality risk in patients with acute heart failure.
An accompanying editorial suggests that the model will require further validation in diverse populations. If it is able to identify a large group of low-risk patients presenting to the emergency department, the next challenge may be understanding how to best manage these patients outside of the hospital.
The Latest Highlights From ACP Journal Club
Are antibiotics beneficial after incision and drainage of a small abscess?
Ann Intern Med. 2017;167:JC39. doi:10.7326/ACPJC-2017-167-8-039
This study randomly assigned 786 children and adults with small skin abscesses (≤5 cm in diameter in adults, smaller in children) and without fever, systemic inflammatory response syndrome, or immunocompromise to receive clindamycin, trimethoprim–sulfamethoxazole (TMP-SMX), or placebo for 10 days after incision and drainage of the abscess. Either treatment resulted in statistically significantly higher clinical cure rates than placebo at 7 to 10 days (clindamycin, 83%; TMP-SMX, 82%; placebo, 69%) and at 30 days (clindamycin, 79%; TMP-SMX, 73%; placebo, 63%). Clindamycin use was associated with significantly higher rates of diarrhea than TMP-SMX or placebo.
Is it beneficial to add TMP-SMX to cephalexin when treating nonpurulent cellulitis?
Ann Intern Med. 2017;167:JC40. doi:10.7326/ACPJC-2017-167-8-040
In this study, 500 adults with cellulitis, without abscess or purulent drainage (confirmed by ultrasound evaluation), and without immunocompromise or intravenous drug use were randomly assigned to receive cephalexin plus TMP-SMX or cephalexin alone for 7 days. The addition of TMP-SMX did not improve outcomes, including rates of cure, hospitalization, or surgical procedures. These findings support the observation that Staphylococcus aureus is an uncommon cause of nonpurulent cellulitis.
Is triple therapy more effective than oseltamivir monotherapy for severe influenza infection?
Ann Intern Med. 2017;167:JC41. doi:10.7326/ACPJC-2017-167-8-041
This RCT compared 30-day mortality in 217 adults (median age 80 to 82 years) who were hospitalized for severe influenza A infection with evidence of fever and chest infiltrate. Patients were randomly assigned to receive either triple therapy (clarithromycin, naproxen, and oseltamivir) or oseltamivir alone. Patients receiving triple therapy had significantly lower mortality at 30 days (0.9% vs. 8.2%, respectively) and 90 days (1.9% vs. 10%, respectively).
Does the long-term use of azithromycin improve outcomes in asthma with uncontrolled symptoms despite maintenance inhaler treatment?
Ann Intern Med. 2017;167:JC42. doi:10.7326/ACPJC-2017-167-8-042
This RCT examined 420 adult patients with symptomatic asthma despite the use of maintenance inhaled corticosteroids or long-acting bronchodilators. Patients were randomly assigned to either oral azithromycin (500 mg 3 times/wk) or placebo for 48 weeks. Patients receiving azithromycin had significantly fewer moderate and severe exacerbations (relative risk reduction, 25%; 95% CI, 10 to 38) and higher asthma-related quality-of-life scores (although the latter are of doubtful clinical significance). How azithromycin might compare with other adjunctive therapies for persistently symptomatic asthma (e.g., additional inhaled therapy, a leukotriene inhibitor, or a biologic) remains unclear and a topic of future inquiry.
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