Jeffrey M. Rohde

Health Care–Associated Infection After Red Blood Cell Transfusion: A Systematic Review and Meta-analysis

IMPORTANCE The association between red blood cell (RBC) transfusion strategies and health care-associated infection is not fully understood. OBJECTIVE To evaluate whether RBC transfusion thresholds are associated with the risk of infection and whether risk is independent of leukocyte reduction. DATA SOURCES MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Cochrane Database of Sytematic Reviews, ClinicalTrials.gov, International Clinical Trials Registry, and the International Standard Randomized Controlled Trial Number register were searched through January 22, 2014. STUDY SELECTION Randomized clinical trials with restrictive vs liberal RBC transfusion strategies. DATA EXTRACTION AND SYNTHESIS Twenty-one randomized trials with 8735 patients met eligibility criteria, of which 18 trials (n = 7593 patients) contained sufficient information for meta-analyses. DerSimonian and Laird random-effects models were used to report pooled risk ratios. Absolute risks of infection were calculated using the profile likelihood random-effects method. MAIN OUTCOMES AND MEASURES Incidence of health care-associated infection such as pneumonia, mediastinitis, wound infection, and sepsis. RESULTS The pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and serious infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity (I2 = 0%; τ2 <.0001). The number needed to treat (NNT) with restrictive strategies to prevent serious infection was 38 (95% CI, 24-122). The risk of infection remained reduced with a restrictive strategy, even with leukocyte reduction (RR, 0.80 [95% CI, 0.67-0.95]). For trials with a restrictive hemoglobin threshold of <7.0 g/dL, the RR was 0.82 (95% CI, 0.70-0.97) with NNT of 20 (95% CI, 12-133). With stratification by patient type, the RR was 0.70 (95% CI, 0.54-0.91) in patients undergoing orthopedic surgery and 0.51 (95% CI, 0.28-0.95) in patients presenting with sepsis. There were no significant differences in the incidence of infection by RBC threshold for patients with cardiac disease, the critically ill, those with acute upper gastrointestinal bleeding, or for infants with low birth weight. CONCLUSIONS AND RELEVANCE Among hospitalized patients, a restrictive RBC transfusion strategy was associated with a reduced risk of health care-associated infection compared with a liberal transfusion strategy. Implementing restrictive strategies may have the potential to lower the incidence of health care-associated infection.

Identifying patients with severe sepsis using administrative claims: Patient-level validation of the angus implementation of the international consensus conference definition of severe sepsis

Background:Severe sepsis is a common and costly problem. Although consistently defined clinically by consensus conference since 1991, there have been several different implementations of the severe sepsis definition using ICD-9-CM codes for research. We conducted a single center, patient-level validation of 1 common implementation of the severe sepsis definition, the so-called “Angus” implementation. Methods:Administrative claims for all hospitalizations for patients initially admitted to general medical services from an academic medical center in 2009–2010 were reviewed. On the basis of ICD-9-CM codes, hospitalizations were sampled for review by 3 internal medicine-trained hospitalists. Chart reviews were conducted with a structured instrument, and the gold standard was the hospitalists’ summary clinical judgment on whether the patient had severe sepsis. Results:Three thousand one hundred forty-six (13.5%) hospitalizations met ICD-9-CM criteria for severe sepsis by the Angus implementation (Angus-positive) and 20,142 (86.5%) were Angus-negative. Chart reviews were performed for 92 randomly selected Angus-positive and 19 randomly-selected Angus-negative hospitalizations. Reviewers had a &kgr; of 0.70. The Angus implementation’s positive predictive value was 70.7% [95% confidence interval (CI): 51.2%, 90.5%]. The negative predictive value was 91.5% (95% CI: 79.0%, 100%). The sensitivity was 50.4% (95% CI: 14.8%, 85.7%). Specificity was 96.3% (95% CI: 92.4%, 100%). Two alternative ICD-9-CM implementations had high positive predictive values but sensitivities of <20%. Conclusions:The Angus implementation of the international consensus conference definition of severe sepsis offers a reasonable but imperfect approach to identifying patients with severe sepsis when compared with a gold standard of structured review of the medical chart by trained hospitalists.

The HCAP Gap: Differences between Self-Reported Practice Patterns and Published Guidelines for Health Care-Associated Pneumonia

BACKGROUND Health care-associated pneumonia (HCAP) is prevalent among hospitalized patients. In contrast to community-acquired pneumonia (CAP), patients with HCAP are at increased risk for multidrug-resistant organisms, and appropriate initial antibiotic therapy is associated with reduced mortality. METHODS An online survey was distributed to faculty and housestaff at 4 academic medical centers. The survey required respondents to choose initial antibiotic therapy for 9 hypothetical pneumonia cases (7 cases of HCAP and 2 cases of CAP). Answers were considered correct if the antibiotic regimen chosen was consistent with published guidelines. In addition, physicians rated their knowledge of current guidelines, as well as their level of agreement with guideline recommendations. RESULTS Surveys were sent to 1313 physicians with a response rate of 65% (n = 855). Respondents included physicians in the following categories: hospital medicine/internal medicine, 60%; emergency medicine, 25%; and critical care, 13%. Respondents selected guideline-concordant antibiotic regimens 78% of the time for CAP, but only 9% of the time for HCAP. Because mean scores for HCAP questions were extremely low (mean, 0.63 correct answers out of 7), differences in performance between groups were too small to be meaningful. Despite their poor performance, 71% of the respondents stated that they are aware of published guidelines for HCAP, and 79% stated that they agree with and practice according to the guidelines. CONCLUSIONS In this survey, physicians reported they were aware of, agreed with, and practiced according to published pneumonia guidelines; however, the overwhelming majority did not choose guideline-concordant therapy when tested.

The epidemiology of acute organ system dysfunction from severe sepsis outside of the intensive care unit.

BACKGROUND Severe sepsis is a common, costly, and complex problem, the epidemiology of which has only been well studied in the intensive care unit (ICU). However, nearly half of all patients with severe sepsis are cared for outside the ICU. OBJECTIVE To determine rates of infection and organ system dysfunction in patients with severe sepsis admitted to non-ICU services. DESIGN Retrospective cohort study. SETTING A large, tertiary, academic medical center in the United States. PATIENTS Adult patients initially admitted to non-ICU medical services from 2009 through 2010. MEASUREMENTS All International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were screened for severe sepsis. Three hospitalists reviewed a sample of medical records evaluating the characteristics of severe sepsis. RESULTS Of 23,288 hospitalizations, 14% screened positive for severe sepsis. A sample of 111 cases was manually reviewed, identifying 64 cases of severe sepsis. The mean age of patients with severe sepsis was 63 years, and 39% were immunosuppressed prior to presentation. The most common site of infection was the urinary tract (41%). The most common organ system dysfunctions were cardiovascular (hypotension) and renal dysfunction occurring in 66% and 64% of patients, respectively. An increase in the number of organ systems affected was associated with an increase in mortality and eventual ICU utilization. Severe sepsis was documented by the treating clinicians in 47% of cases. CONCLUSIONS Severe sepsis was commonly found and poorly documented on the wards at our medical center. The epidemiology and organ dysfunctions among patients with severe sepsis appear to be different from previously described ICU severe sepsis populations.

The Epidemiology of Acute Organ System Dysfunction from Severe Sepsis Outside of the ICU

BACKGROUND Severe sepsis is a common, costly, and complex problem, the epidemiology of which has only been well studied in the intensive care unit (ICU). However, nearly half of all patients with severe sepsis are cared for outside the ICU. OBJECTIVE To determine rates of infection and organ system dysfunction in patients with severe sepsis admitted to non-ICU services. DESIGN Retrospective cohort study. SETTING A large, tertiary, academic medical center in the United States. PATIENTS Adult patients initially admitted to non-ICU medical services from 2009 through 2010. MEASUREMENTS All International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were screened for severe sepsis. Three hospitalists reviewed a sample of medical records evaluating the characteristics of severe sepsis. RESULTS Of 23,288 hospitalizations, 14% screened positive for severe sepsis. A sample of 111 cases was manually reviewed, identifying 64 cases of severe sepsis. The mean age of patients with severe sepsis was 63 years, and 39% were immunosuppressed prior to presentation. The most common site of infection was the urinary tract (41%). The most common organ system dysfunctions were cardiovascular (hypotension) and renal dysfunction occurring in 66% and 64% of patients, respectively. An increase in the number of organ systems affected was associated with an increase in mortality and eventual ICU utilization. Severe sepsis was documented by the treating clinicians in 47% of cases. CONCLUSIONS Severe sepsis was commonly found and poorly documented on the wards at our medical center. The epidemiology and organ dysfunctions among patients with severe sepsis appear to be different from previously described ICU severe sepsis populations.

Role of the Hospitalist in Antimicrobial Stewardship: A Review of Work Completed and Description of a Multisite Collaborative

BACKGROUND Historically, antimicrobial stewardship programs have been led by infectious-disease physicians and pharmacists. With the growing presence of hospitalists in health and hospital systems, combined with their focus on quality improvement and patient safety, this emerging medical specialty has the potential to fill essential roles in antimicrobial stewardship programs. OBJECTIVE The goal of this article was to present the reasons hospitalists are ideally positioned to fill antimicrobial-stewardship roles, a narrative review of previously reported hospitalist-led antibiotic-stewardship projects, and a description of an ongoing multisite collaborative by the Institute for Healthcare Improvement (IHI) and the Centers for Disease Control and Prevention (CDC). METHODS A review of the published literature was performed, including an extensive review of the abstracts submitted to the Society of Hospital Medicine annual meetings. RESULTS A number of examples of hospitalists developing and leading antimicrobial-stewardship programs are described. The details of a current multisite IHI/CDC hospitalist-focused initiative are discussed in detail. CONCLUSIONS Hospitalists are actively involved with, and even lead, a variety of antimicrobial-stewardship programs in several different hospital systems. A large, multisite collaborative focused on hospitalist-led antimicrobial stewardship is currently in progress.

Haemovigilance of reactions associated with red blood cell transfusion: comparison across 17 Countries

The recent establishment of the National Healthcare Safety Network Hemovigilance Module in the United States affords an opportunity to compare results with those of other developed nations.

Leadership at the front line: a clinical partnership model on general care inpatient units.

Hospitals strive to provide all their patients with quality care that is safe, timely, efficient, equitable, effective, and patient centered. Although hospitals have developed technology- and industry-based quality improvement models, there remains a need to better engage the frontline health care workers at the site of care to enhance communication and coordination of care. To foster the work environment and relationships in the general acute care units, the authors describe a leadership model that partners a nurse manager with a physician director to build a local clinical care environment that seeks to enhance the whole patient care experience.

Variation in practice patterns among specialties in the acute management of atrial fibrillation

BackgroundAtrial fibrillation (AF) is commonly managed by a variety of specialists. Current guidelines differ in their recommendations leading to uncertainty regarding important clinical decisions. We sought to document practice pattern variation among cardiologists, emergency physicians (EP) and hospitalists at a single academic, tertiary-care center.MethodsA survey was created containing seven clinical scenarios of patients presenting with AF. We analyzed respondent choices regarding rate vs rhythm control, thromboembolic treatment and hospitalization strategies. Finally, we contrasted our findings with a comparable Australasian survey to provide an international reference.ResultsThere was a 78% response rate (124 of 158), 37% hospitalists, 31.5% cardiologists, and 31.5% EP. Most respondents chose rate over rhythm control (92.2%; 95% CI, 89.1% - 94.5%) and thromboembolic treatment (67.8%; 95% CI, 63.8% - 71.7%). Compared to both hospitalists and EPs, cardiologists were more likely to choose thromboembolic treatment for new and paroxysmal AF (adjusted OR 2.38; 95% CI, 1.05 - 5.41). They were less likely to favor hospital admission across all types of AF (adjusted OR 0.36; 95% CI, 0.17 - 0.79) but thought cardiology consultation was more important (adjusted OR 1.88, 95% CI, 0.97 - 3.64). Australasian physicians were more aggressive with rhythm control for paroxysmal AF with low CHADS2 score compared to US physicians.ConclusionsSignificant variation exists among specialties in the management of acute AF, likely reflecting a lack of high quality research to direct the provider. Future studies may help to standardize practice leading to decreased rates of hospitalization and overall cost.

Targeted communication intervention using nursing crew resource management principles.

COMMUNICATION among the health care team is one of the most critical aspects in health care delivery because of its impact on patient safety. The Joint Commission1 has cited miscommunication as one of the primary and consistent root causes for sentinel events. Crew resource management (CRM), a training method that focuses on the management of human error and risk reduction in the environment, has been instrumental in supporting aviation’s excellent safety record and has unique characteristics that