Anthony C. Breu

Preferences for Resuscitation and Intubation Among Patients With Do-Not-Resuscitate/Do-Not-Intubate Orders

OBJECTIVE To determine the accuracy of do-not-resuscitate/do-not-intubate (DNR/DNI) orders in representing patient preferences regarding cardiopulmonary resuscitation (CPR) and intubation. PATIENTS AND METHODS We conducted a prospective survey study of patients with documented DNR/DNI code status at an urban academic tertiary care center that serves approximately 250,000 patients per year. From October 1, 2010, to October 1, 2011, research staff enrolled a convenience sample of patients from the inpatient medical service, providing them with a series of emergency scenarios for which they related their treatment preference. We used the Kendall τ rank correlation coefficient to examine correlation between degree of illness reversibility and willingness to be resuscitated. Using bivariate statistical analysis and multivariate logistic regression analysis, we examined predictors of discrepancies between code status and patient preferences. Our main outcome measure was the percentage of patients with DNR/DNI orders wanting CPR and/or intubation in each scenario. We hypothesized that patients with DNR/DNI orders would frequently want CPR and/or intubation. RESULTS We enrolled 100 patients (mean ± SD age, 78 ± 13.7 years). A total of 58% (95% CI, 48%-67%) wanted intubation for angioedema, 28% (95% CI, 20%-3.07%) wanted intubation for severe pneumonia, and 20% (95% CI, 13%-29%) wanted a trial resuscitation for cardiac arrest. The desire for intubation decreased as potential reversibility of the acute disease process decreased (Kendall τ correlation coefficient, 0.45; P<.0002). CONCLUSION Most patients with DNR/DNI orders want CPR and/or intubation in hypothetical clinical scenarios, directly conflicting with their documented DNR/DNI status. Further research is needed to better understand the discrepancy and limitations of DNR/DNI orders.

Utility, charge, and cost of inpatient and emergency department serum folate testing

BACKGROUND Serum folate levels are commonly ordered for multiple indications in the inpatient and emergency department settings. Since mandatory folic acid fortification in 1998, there has been a decreasing prevalence of folate deficiency in the United States. OBJECTIVE Our objective was to determine the indications, rate of deficiency, charge and cost per deficient result, and change in management per deficient result in serum folate testing in inpatients and emergency department patients. DESIGN Retrospective analysis of all inpatient and emergency department serum folate tests. METHODS We analyzed all inpatient and emergency department serum folate tests performed over a 12-month period. We reviewed the charts of 250 patients and all low-normal or deficient serum folate levels to determine indications, comorbidities, and change in management based on result. Charge and cost analyses were performed. SETTING/PATIENTS All inpatient and emergency department patients with a serum folate test performed at a major medical center in Boston, Massachusetts. RESULTS A total of 2093 serum folate tests were performed in 1944 patients with 2 deficient levels. The most common indications were anemia without macrocytosis and anemia with macrocytosis. The amount charged per deficient result was

Serum and red blood cell folate testing on hospitalized patients

158,022. The cost to the hospital per deficient result was less than

Prompt Extubation After Intensive Care Unit Procedures: A Teachable Moment

2093. CONCLUSIONS In folic acid fortified countries, serum folate testing has low utility and poor cost effectiveness for all indications in inpatients and emergency department patients.

Differentiating DNI from DNR: Combating code status conflation

Medical Service, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts; Harvard Medical School, Boston, Massachusetts; Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Divisions of General Internal Medicine and Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland; Johns Hopkins School of Medicine, Baltimore, Maryland.

The UNOS ‘preferential allocation’ concept proposal for the allocation of deceased donor kidney transplants: implications for patients with diabetes

Story From the Front Lines An80-year-oldmanpresentedwithacutenon–ST-segment elevation myocardial infarction requiring cardiac catheterization. His medical history included coronary artery disease with resultant ischemic cardiomyopathy, peripheral vascular disease, and hypothyroidism. Prior to cardiac catheterization, the patient became agitated and confused and was unable to remain still, so the decision was made to intubate and sedate him for the procedure. After catheterization with placement of multiple stents, the patient remained intubated and sedated on propofol and was transferred to the cardiac care unit. Given his agitation, instructions from the attending cardiologist to the covering resident were to keep the patient intubated overnight to allow him to rest. Several hours after the procedure, the patient became hypotensive with systolic blood pressures of 70 to 80 mm Hg; his blood pressure improved with reduction of his minute dose of propofol, which was thus thought to be the cause of his hypotension. An arterial blood gas sample showed normal values, and the patient had a normal oxygen saturation on a 40% fraction of inspired oxygen. He was following commands while awake and was otherwise appropriate for extubation. The covering resident contacted the cardiology fellow to discuss extubation, but given the attending cardiologist’s clear instructions to keep the patient intubated, the patient was left on the ventilator. Neither the resident nor the fellow were certain that the issue warranted paging the attending in the middle of the night. After sedatives were switched to midazolam and fentanyl, the patient’s blood pressure improved. He was successfully extubated the following afternoon, approximately 20 hours after the procedure.

The 60-Minute Root Cause Analysis: A Workshop to Engage Interdisciplinary Clinicians in Quality Improvement

Goals of care discussions, including those focused on code status, are meant to foster autonomous decision making. Unfortunately, these discussions often conflate decisions regarding the use of cardiopulmonary resuscitation for cardiac arrest and mechanical ventilation for prearrest respiratory failure. They also exclude discussions of outcomes, particularly those associated with prearrest respiratory failure. In doing so, they may fail in their intention of extending patient autonomy. Journal of Hospital Medicine 2014;9:669-670.

A Multicenter Study Into Causes of Severe Acute Liver Injury

Kidney transplantation is highly cost-effective [1] and remains the preferred treatment for end-stage renal disease (ESRD), a condition affecting over half of a million Americans with annual costs exceeding US

Making progress with code status documentation.

25 billion [2]. Transplantation offers a clear survival advantage for qualifying patients compared to dialysis [3]. Unfortunately, the disparity between supply and demand for transplantable kidneys continues to increase. The current waiting list for a kidney transplant now includes over 93 000 patients [4]. In the Scientific Registry of Transplant Recipients 2009 report, there were 10 101 deceased donor kidney transplants and 5966 live donor transplants in 2008, leaving an estimated 76 089 patients still waiting for a transplant [5]. Two patient cohorts, those with diabetes and the elderly, disproportionately contribute to the disease burden of ESRD in the USA. Diabetes causes 44% of new cases of ESRD, >200 000 patients are currently on dialysis or living with a kidney transplant as a result of diabetic nephropathy [2]. The proportion of incident elderly dialysis patients who have diabetes also continues to rise. Between 2000 and 2030, the estimated number of people with diabetes in age groups 45–64 and >65 years will likely double [6]. There is substantial evidence to support kidney transplantation for patients with diabetes. The proportion of diabetic recipients has increased >10-fold since 1970 [7] due to improved care of uremic diabetic patients and higher transplant success rates, particularly early graft survival. Curves of graft survival comparing non-diabetic and diabetic recipients begin to diverge only after ~3 years [7]. Most importantly, as Wolfe et al. [3] demonstrated that the long-term mortality for deceased donor transplant recipients was 48–82% lower compared to patients on the waiting list, with young diabetics experiencing even greater benefit than non-diabetics. In summary, kidney transplantation remains the treatment of choice for diabetic patients with ESRD. Nonetheless, evidence indicates that, for patients with diabetes, the likelihood of being listed for transplant as well as for actually receiving one is less than for other individuals [8, 9]. The result is that patients with diabetes are more likely to die before receiving a deceased donor kidney transplant. The current allocation system for deceased donor kidneys uses a point system determined by waiting time, patient sensitization (anti-HLA antibodies) and tissue matching. Of these factors, the main determinant for allocation is candidate’s waiting time. This is in contrast to lung and liver transplantation policies which focus on reducing mortality in the recipient candidate pool by weighing the severity of a candidate’s condition. In 2011, the Organ Procurement and Transplantation Network proposed a major change to the current 20-yearold kidney allocation policy [10]. The new policy of ‘preferential allocation’ to achieve better survival matching between the donated kidney and its recipient introduces two new metrics to allocation. The first is a kidney donor profile index (KDPI) aimed at identifying the highest quality kidneys [11]. This is coupled with an estimated post-transplant score (EPTS), a measure of a recipient’s predicted life expectancy after transplantation. The EPTS calculation is based on four factors felt to provide a ‘reasonable estimate’ of identifying candidates with the longest post-transplant survival: length of time on dialysis, any prior organ transplant, diabetic status and age. Together, the KDPI and EPTS will be used to match the best 20% of donor kidneys to candidates with the longest expected posttransplantation survival. Afterward, a 30-year age range will be used to allocate the remaining 80% of organs.

Low Yield of Outpatient Serum Folate Testing: Eleven Years of Experience

Introduction We created a standardized workshop to engage residents in quality improvement (QI) using the root cause analysis model. The workshop allows for a robust learning experience while providing solutions derived from clinicians to address important local problems. No prerequisite knowledge or experience is required. Methods The workshop is facilitated by one or more moderators, ideally with experience in QI. An interdisciplinary group of residents, medical students, nurses, and other attendees comprise an audience which actively engages in workshop activities. Facilitators follow a scripted model to teach important patient safety concepts with frequent break-outs for hands-on application of QI tools. During the workshop, participants create a process map and fishbone diagram, as well as develop and critically evaluate novel interventions. Results Over the course of one academic year, the workshop has been implemented 17 times with roughly 25 internal medicine residents in attendance at each workshop. In addition, the workshop was run online for 126 participants with varied exposure to QI techniques. Forty percent of these participants completed a survey indicating that over 89% learned something new, 87% felt they could apply the material to their work, and 95% would recommend the workshop to a colleague. Discussion This 60-minute workshop can provide hands-on QI experience in a standardized format to achieve the dual objectives of teaching QI to clinicians and allowing them to generate innovations. The module can be used for internal case development and trainee participation, but prepared cases are provided for facilitators without the resources for local case development.