Jeffrey H. Jennings

Predischarge bundle for patients with acute exacerbations of COPD to reduce readmissions and ED visits: a randomized controlled trial.

BACKGROUND Hospital readmissions for acute exacerbations of COPD (AECOPDs) pose burdens to the health-care system and patients. A current gap in knowledge is whether a predischarge screening and educational tool administered to patients with COPD reduces readmissions and ED visits. METHODS A single-center, randomized trial of admitted patients with AECOPDs was conducted at Henry Ford Hospital between February 2010 and April 2013. One hundred seventy-two patients were randomized to either the control (standard care) or the bundle group in which patients received smoking cessation counseling, screening for gastroesophageal reflux disease and depression or anxiety, standardized inhaler education, and a 48-h postdischarge telephone call. The primary end point was the difference in the composite risk of hospitalizations or ED visits for AECOPD between the two groups in the 30 days following discharge. A secondary end point was 90-day readmission rate. RESULTS Of the 172 patients, 18 of 79 in the control group (22.78%) and 18 of 93 in the bundle group (19.35%) were readmitted within 30 days. The risk of ED visits or hospitalizations within 30 days was not different between the groups (risk difference, -3.43%; 95% CI, -15.68% to 8.82%; P = .58). Overall, the time to readmission in 30 and 90 days was similar between groups (log-rank test P = .71 and .88, respectively). CONCLUSIONS A predischarge bundle intervention in AECOPD is not sufficient to reduce the 30-day risk of hospitalizations or ED visits. More resources may be needed to generate a measurable effect on readmission rates. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02135744; URL: www.clinicaltrials.gov.

Dedicated Multidisciplinary Ventilator Bundle Team and Compliance with Sedation Vacation

BACKGROUND How compliance with a ventilator bundle is monitored varies from institution to institution. Some institutions rely on the primary intensive care unit team to review the bundle during their rounds; others rely on a separate team of health care personnel that may include representatives from disciplines such as nursing, respiratory therapy, and pharmacy. OBJECTIVES To compare rates of compliance with ventilator bundle components between a dedicated ventilator bundle rounding team and the primary intensive care unit rounding team in a 68-bed medical intensive care unit. METHODS A query of the medical intensive care units database was used to retrospectively determine rates of compliance with specific ventilator bundle components at a tertiary care hospital in an urban community for 1 year. RESULTS Compared with the intensive care unit rounding team, the ventilator bundle rounding team had better compliance with sedation vacation (61.7% vs 54.0%, P < .001). Rates of compliance with spontaneous breathing trials and prophylaxis of peptic ulcer disease were similar in both study groups. CONCLUSIONS A dedicated ventilator bundle rounding team improves compliance with sedation vacation, but not with spontaneous breathing trials and prophylaxis of peptic ulcer disease. In a large-volume tertiary center, a dedicated ventilator bundle rounding team may be more effective than the primary rounding team in achieving compliance with some bundle components.

Preliminary Analysis of a Modified Screening Tool to Increase the Frequency of Palliative Care Consults

Purpose: Palliative care interventions have been shown to improve patient quality of life but the benefit may be less if interventions occur late in the patient’s disease process. The objective of this study was to evaluate whether an objective screening tool could improve the frequency and timeliness of palliative care consultation. Methods: Using a quasi-experimental design with 2 geographically separate medical intensive care units (MICUs), the control MICU continued existing consultation practice and the intervention MICU implemented a screening tool with each new admission. Any item checked on the screening tool triggered a palliative care consult within 24 hours of admission to the MICU. Results: A total of 223 MICU admissions were evaluated: 156 patients in the control group and 67 patients in the intervention group. More consults were generated in the intervention group (22.39%) compared to the control group (7.05%; P < .001). The median time to consultation was lower in the intervention group compared to the control group (1 day vs 2 days; P < .01). Conclusion: Implementing a simple, objective screening tool increased palliative consultation rates and decreased median time to palliative consultation in our institution’s MICU.

Anaerobic antibiotic usage for pneumonia in the medical intensive care unit

Pneumonia is a common admitting diagnosis in the intensive care unit (ICU). When aspiration is suspected, antibiotics to cover anaerobes are frequently used, but in the absence of clear risk factors, current guidelines have questioned their role. It is unknown how frequently these guidelines are followed.

Low Rate of Adverse Events Associated with Inpatient Parenteral Prostacyclins

Abstract: Parenteral prostacyclin is the most-effective therapy for patients with pulmonary arterial hypertension. Administration is complex, and administration errors are potentially life threatening. Hospital policies to minimize the risk to patients are necessary, but their effectiveness has not been well studied. We quantified the adverse event incident rate per at-risk patient day in a tertiary care hospital with an established parenteral prostacyclin policy. Patients on parenteral prostacyclin including new initiations from January 2003 to January 2013 were identified, encompassing 386 discrete admissions. Reports of adverse events were obtained from the inpatient risk feedback–reporting process and detailed chart review. Policy-divergent events were analyzed both categorically and by the degree of severity. Overall, 153 total policy-divergent events were identified. Data analysis indicated an incident rate of 45.9 per 1,000 patient days. In total, 21 of 153 potential errors reached the patient, translating to an incident rate of 6.3 per 1,000 patient days. Incident rate for “serious symptomatic” or “catastrophic” policy-divergent events was 3.3 per 1,000 patient days. Even with specific prostacyclin training and administration policy, there remains a small risk of adverse events in hospitalized pulmonary hypertension patients receiving parenteral prostacyclin.

Aripiprazole-induced hypersensitivity pneumonitis

Aripiprazole is an atypical antipsychotic agent commonly used in the management of schizophrenia. Aripiprazole has not been reported to have an association with interstitial lung disease. We describe a case of a 36-year-old woman who began to experience respiratory issues shortly after starting aripiprazole and presented to us 4 years later with progressive exertional shortness of breath. High-resolution CT of the chest showed a bilateral ground glass pattern. Video-assisted thoracoscopy with biopsy revealed alveolar septal thickening and an inflammatory infiltrate composed mainly of lymphocytes, suggestive of chronic hypersensitivity pneumonitis. After discontinuing aripiprazole and initiating prednisolone therapy, the patient’s pulmonary symptoms improved. This case highlights that aripiprazole can cause hypersensitivity pneumonitis in susceptible individuals.

Removal of Self-Expanding Metallic Stents.

Background:Despite their safety profile, self-expanding metallic stents (SEMS) have been difficult to remove. We aim to describe our experience in removal of SEMS at Henry Ford Hospital with a specific emphasis on safety. Methods:We reviewed the charts of all patients who underwent removal of a SEMS at Henry Ford Hospital between 2003 and 2013. We recorded demographic information, indication for initial stent placement, indication for stent removal, time to stent removal, procedure of removal, and any complications. Results:In all, 19 stents were removed in 16 separate procedures in 14 patients. The median age was 62 years, and 50% of the patients were female. Stents were removed at a median of 35 days (range, 2 to 595 d). No complications occurred in 10/16 (62.5%) procedures. In the remaining 5 patients, complications were not directly related to the stent removal, and serious complications were mostly related to severity of underlying lung disease. Of the 10 procedures done as outpatients, 70% were discharged immediately after the procedure. Conclusions:Removal of SEMS can be done safely. Routine postoperative ventilation and intensive care unit monitoring is not required. In the absence of severe underlying lung disease, patients can safely be discharged if there are no immediate postprocedure complications.