Inpatient Notes
Trends in Rates of Catheter-Associated Bloodstream Infection—Zeroing In on Zero or Just Fake News?
—Naomi P. O’Grady, MD
In recent years, rates of catheter-associated bloodstream infections have dropped dramatically. In this issue's Inpatient Notes, the author discusses the interventions that may have brought about this improvement and suggests that the numbers may not be telling the whole story.
Highlights of Recent Articles From Annals of Internal Medicine
Outcomes of Dabigatran and Warfarin for Atrial Fibrillation in Contemporary Practice: A Retrospective Cohort Study
Ann Intern Med. 2017;167:845-854. Published 14 November 2017. doi:10.7326/M16-1157
This large retrospective study analyzed data from the U.S. Food and Drug Administration Sentinel Initiative, a national surveillance system, to compare rates of ischemic stroke, intracranial hemorrhage, extracranial bleeding, and myocardial infarction (MI) in patients taking warfarin or dabigatran. Investigators compared 25 289 patients starting warfarin with 25 289 propensity score-matched patients starting dabigatran for atrial fibrillation. The analysis revealed that patients treated with dabigatran had similar rates of ischemic stroke and extracranial bleeding as patients taking warfarin; however, they experienced less frequent intracranial bleeding (0.39 vs. 0.77 events per 100 person-years; hazard ratio, 0.51 [CI, 0.33 to 0.79]) but more frequent MI (0.77 vs. 0.43 events per 100 person-years; hazard ratio, 1.88 [CI, 1.22 to 2.90]).
Key points for hospitalists include:
In this real-world setting, dabigatran was as equally effective in preventing stroke as warfarin and was associated with fewer intracranial bleeding episodes.
Dabigatran was associated with higher rates of MI than warfarin. However, the authors questioned the validity of this finding, given a lack of statistical significance in sensitivity analyses.
Subgroup analysis did show higher rates of MI in patients treated with dabigatran who were men and were older than 75 years and showed higher rates of gastrointestinal bleeding in patients treated with dabigatran who also had renal dysfunction and were older than 75 years.
Measuring Patient Safety in Real Time: An Essential Method for Effectively Improving the Safety of Care
Ann Intern Med. 2017;167:882-883. Published 21 November 2017. doi:10.7326/M17-2202
This Ideas and Opinions piece describes the electronic health record as a powerful tool in detecting harm from medical error that very few hospitals are using to its full potential. Most hospitals still rely on voluntary reporting to detect errors, but this is known to be an insensitive method for detecting harm. The authors suggest that emerging techniques should allow all hospitals to use their electronic health records to facilitate detection of harm from medical error.
Key points for hospitalists include:
Hospitals can use the electronic health record to search for triggers associated with harmful errors, allowing targeted record reviews. This type of triggered review can detect more than 90% of harm in hospitalized patients.
Hospitals can automate reporting of certain lab values to identify important conditions (e.g., reports of blood cultures results may be used to identify catheter-associated bloodstream infection).
Introducing a Patient Portal and Electronic Tablets to Inpatient Care
Ann Intern Med. 2017;167:816-817. Published 24 October 2017. doi:10.7326/M17-1766
This Ideas and Opinions piece introduces the notion of creating an electronic patient portal for hospitalized patients. Electronic patient portals are frequently used in the outpatient arena and seem to engage patients in their own care. However, they have not been well-studied in the inpatient setting. These portals can allow hospitalized patients to see their own health records, including test results and medication administration records, a roster of the care team, and a daily care plan. They can also allow patients to save notes or questions and to communicate more directly and asynchronously with the care team. A small pilot study conducted by the authors showed that patients using an electronic portal had higher satisfaction scores than contemporaneous controls that did not have access to the portal.
Key points for hospitalists include:
Although evidence is limited, electronic patient portals may be useful in increasing satisfaction and engagement of hospitalized patients.
The Latest Highlights From ACP Journal Club
How should antirheumatic drugs be managed in patients having joint replacement surgery?
Ann Intern Med. 2017;167:JC50. doi:10.7326/ACPJC-2017-167-10-050
This guideline is based on a systematic review of the literature examining studies that addressed perioperative management of antirheumatic medications. Although most of the included evidence was of low quality, recommendations from a panel of experts were almost unanimous in endorsing the following clinical practices: a) to continue perioperative home doses of glucocorticoids (as opposed to stress doses) during surgery; b) to continue nonbiologic disease–modifying antirheumatic drugs in the perioperative setting; and c), to avoid use or initiation of biologic agents in the perioperative period.
How reliable is computed tomography pulmonary angiography (CTPA) for ruling out suspected pulmonary embolism?
Ann Intern Med. 2017;167:JC59. doi:10.7326/ACPJC-2017-167-10-059
In this patient level meta-analysis, data from 4 prospective diagnosis and treatment trials (n = 6148) were analyzed and revealed that for patients with a Wells score >4 and negative CTPA, 2% had venous thromboembolism and 0.48% had fatal pulmonary embolism at 3 months. The findings suggest that although powerful, CTPA is an imperfect test. Thus, it may be useful to maintain a low threshold to reinvestigate patients with negative CTPA and a high clinical probability of disease if symptoms persist or worsen.
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