Connie M. Parenti

The Idle Intravenous Catheter

OBJECTIVE To assess the prevalence of idle peripheral intravenous (IV) catheters (those without any therapeutic use) on regular-care medical wards. DESIGN Observation, interviews, and chart review. SETTING A university-affiliated VA medical center. PATIENTS All 959 inpatients on 4 regular-care medical wards during a 6-week period, including 484 IV catheter episodes and 2983 patient-days of IV catheter use. MAIN OUTCOME MEASURE Idle IV catheter use. RESULTS Thirty-five percent of all IV catheter episodes (95% CI, 32% to 38%) had 2 or more consecutive idle days. In only 6 of these (1%) could a specific reason for the catheter be determined. Seventeen percent of all patients on regular-care medical wards (CI, 15% to 19%) had an idle IV catheter for 2 or more consecutive days. Twenty percent of all patient-days of IV catheter use were idle (CI, 19% to 21%). CONCLUSIONS Our data suggest that IV are frequently used unnecessarily. Future efforts to reduce IV catheter complication rates should focus on reducing unnecessary use as well as on improving techniques to reduce infection rates when use is appropriate.

An internist joins the surgery service: does comanagement make a difference?

Objective: To determine the effect of internist comanagement of cardiothoracic surgical patients on patient outcome and resource utilization.Design: Before/after comparison.Setting: Tertiary care university-affiliated Veterans Affairs hospital.Patients: 165 patients (86 before the intervention and 79 after the intervention) undergoing cardiothoracic surgery.Interventions: All patients were seen preoperatively and at least daily through discharge by a comanaging staff internist who was a full-time member of the surgical team.Main outcome measures: Length of stay, in-hospital mortality, and laboratory and radiology utilization.Results: Significant shortening of postoperative length of stay (18.1 days before and 12.1 days after, p=0.05) and total length of stay (27.2 days before and 19.7 days after, p=0.03) was noted. The inhospital mortality rate for the patients undergoing surgery was 8.1% before the intervention versus 2.5% afterward (p=0.17). There were significant reductions in the total number of x-rays (p=0.02) and nearly significant reductions in total laboratory test utilization (p=0.06). Referring physicians and surgeons both believed that the contribution of the internist was important.Conclusions: The addition of an internist to the cardiothoracic surgery service at a tertiary care teaching center was associated with decreased resource utilization and possible improved outcomes. Before becoming more widely adopted, this intervention deserves further exploration at other sites using stronger study designs.

Variation by specialty in the treatment of urinary tract infection in women

To determine practicing physicians’ strategies for diagnosing and managing uncomplicated urinary tract infection, we surveyed physicians in general internal medicine, family practice, obstetrics and gynecology, and emergency medicine in four states, Responses differed significantly by respondents’ specialty. For example, nitrofurantoin was the antibiotic of first choice for 46% of obstetricians, while over 80% in the other specialties chose trimethoprim-sulfamethoxazole. Most surveyed said they do not usually order urine culture, but the percentage who do varied by specialty. Most use a colony count of 105 colony-forming units or more for diagnosis although evidence favors a lower threshold, and 70% continue antibiotic therapy even if the culture result is negative. This survey found considerable variation by specialty and also among individual physicians regarding diagnosis and treatment of urinary tract infection and also suggests that some of the new information from the literature has not been translated to clinical practice.

Ruptured abdominal aortic aneurysm: The internist as diagnostician

PURPOSE To define the clinical features and assess the frequency and causes of missed diagnoses of ruptured abdominal aortic aneurysm (AAA) in patients initially presenting to internists. PATIENTS All identified patients with ruptured AAA presenting to internists during a 7 1/2-year period at a large academic medical center. METHOD Chart review. RESULTS We identified 23 patients with a ruptured AAA presenting to internists. Most had abdominal pain and tenderness, back or flank pain, and leukocytosis, whereas anemia and profound hypotension (systolic blood pressure below 90 mm Hg) were uncommon at presentation. In 14 cases (61%), the diagnosis of ruptured AAA was initially missed. Nine patients had an interval of 24 hours or more between presentation to the internist and surgery or death. The diagnosis was not made until after shock developed in nine patients who were hemodynamically stable at presentation. Of 17 patients who underwent surgery, 7 of 8 with preoperative shock died, compared with 2 deaths in 9 patients (p < .02) without shock. All six patients who did not have surgery died, yielding an overall mortality of 65% for the series. Ruptured AAAs were most frequently misdiagnosed as urinary tract obstruction or infection, spinal disease, and diverticulitis. Chart review revealed a general lack of physician awareness of the syndromes of contained rupture of AAA and symptomatic unruptured AAA. CONCLUSIONS In patients with ruptured AAA who present to internists, the diagnosis is often delayed or missed and this appears to adversely effect survival. Internists should familiarize themselves with the presentation and management of ruptured AAA.

Effects of a night float system on housestaff neuropsychologic function

To examine the effect of a night float call system (NFS), a battery of neuropsychologic tests was administered to housestaff after call during an overnight call system (ONCS), and the results were compared with the results obtained during a NFS. Although NFS housestaff were less sleep-deprived, results of tests of psychomotor function were not different. Importantly, both groups had high depression, hostility, and anxiety scores. NFS housestaff had small but significantly lower depression scores, which, if not due to time of year, may represent a positive effect of the NFS. Future investigation should be directed at clarifying the aspects of residency training that adversely affect housestaff mood.

High yield of chest radiography in walk-in clinic patients with chest symptoms

Purpose: To assess the yield of chest radiography among a group of symptomatic adults presenting to a walk-in clinic.Patients and methods: Outpatients presenting to a walk-in clinic for evaluation of cough, shortness of breath, or pleuritic chest pain were interviewed by nurses who recorded clinical data pertaining to the present illness and past medical history. Chest radiographs were then obtained prior to physician evaluation.Results: A total of 221 patients were enrolled in the study; 97% were men and the mean age was 62 (±10.3) years. New clinically important radiographic abnormalities, defined as those necessitating acute intervention and/or follow-up evaluation, were identified for 77 (34.8%) of the 221 patients studied. Abnormalities included 39 (17.6%) cases of infiltrates, 23 (10.4%) cases of nodules or mass lesions, and 19 (8.6%) cases of cardiomegaly or congestive heart failure. Evaluation of clinical data obtained during the triage interview revealed no statistically significant difference between those patients with and those without new radiographic abnormalities on their chest x-rays.Conclusion: Adult patients similar to those described in this study who present to a walk-in clinic with a chief complaint of cough, dyspnea, or pleuritic chest pain have a high likelihood of having new clinically important abnormalities found on their chest radiographs. Since patient characteristics did not predict which patients were more likely to have abnormal findings, the practice of obtaining chest radiographs for such individuals at the time of triage and prior to physician evaluation appears justified.

Prescription drug costs as a reason for changing physicians

The authors conducted a telephone survey of 200 patients who had recently transferred their health care to a Veterans Affairs (VA) medical center. Of the study patients, 56% considered prescription drug costs to be the main reason or a major contributing reason for transfer (95% confidence interval 49% to 63%). The mean out-of-pocket prescription drug cost for these patients was

The relationship between treatment objectives and practice patterns in the management of urinary tract infections

139 per month, compared with

Changing the fourth-year medicine clerkship structure: a successful model for a teaching service without housestaff.

47 per month for patients for whom drug costs were a minor reason or not a reason at all (p<0.001). Drug costs are a principal reason for patients to transfer their health care to the VA.

Multi-site reliability and validity of a diagnostic pattern-recognition knowledge-assessment instrument.

Objective. To describe physicians’ goals when treating uncomplicated urinary tract infections (UTIs) and the relationship between goals and practice patterns. Study design. Analysis of survey results. Population. Primary care physicians. Outcomes measured. Self-reported treatment objectives and practice patterns. Results. Most physicians reported their UTI management was convenient for the patient (81.3%). Fewer stated they minimized patients’ costs (53.4%), made an accurate diagnosis (56.7%), or avoided unnecessary antibiotics (40.9%). Physicians who stressed convenience or minimizing patient expenses were less likely to use many resources (urine culture, microscopic urinalysis, followup visits and tests, and prolonged antibiotic treatment) and more likely to use telephone treatment. Physicians who stressed accurate diagnoses or avoiding unnecessary antibiotics were more likely to use the same resources and less likely to use telephone treatment. Conclusion. UTI management goals vary across physicians and are associated with different clinical approaches. Differences in treatment objectives may help explain variations in practice patterns.