What’s New in the Patient Safety World

August 2014

 

·         The Weekend Effect in Pediatric Surgery

·         More Questions About Beta Blockers in MI

·         Cataract Surgery and Falls

·         A New Rapid Screen for Delirium in the Elderly

·         Delirium in Pediatrics

 

 

 

 

The Weekend Effect in Pediatric Surgery

 

 

The “weekend effect” in which mortality and complications occur more frequently in patients admitted on weekends or operated upon on weekends compared to weekdays has been reported for multiple conditions. Various studies have demonstrated higher mortality rates for patients admitted on weekends with strokes, atrial fibrillation, diverticulosis surgery, a variety of other surgical procedures, head trauma, COPD, CHF, perinatal events, ICU admissions, ESRD, and other conditions. Note that we sometimes use the term “after hours effect” since some of the same issues occur in patients admitted at night.

 

Now a new study demonstrates the “weekend effect” also affects children undergoing surgery (Goldstein 2014). The researchers analyzed data over a 22 year period and noted that children who underwent urgent or emergency surgery on weekends were 63% more likely to die and 40% more likely to have complications than comparable patients operated upon on weekdays. They were also 15% more likely to receive blood transfusions. The surgeries analyzed were common surgeries (abscess drainage, appendectomy, inguinal hernia repair, open fracture reduction with internal fixation, or placement/revision of ventricular shunt) and the above findings were found even after adjustment for patient characteristics. While the absolute numbers of death were actually quite small the study does suggest that many of the same factors which come into play in adults also impact children.

 

The study did not determine which specific factors were responsible for the “weekend effect”. Our November 2013 What’s New in the Patient Safety World column “The Weekend Effect: Not One Simple Answer” highlighted a study from Australia (Concha 2013) which showed that for most of the DRG’s showing excess mortality with weekend admission there are both patient-related factors and care-related factors in play.

 

We’ve discussed many of the contributory factors in our many columns related to the weekend effect (see list at the end of today’s column). Our healthcare systems clearly do not deliver uniform care 24x7. The differences between the hospital during weekday daytime hours and the hospital at night and on weekends is striking. Staffing patterns (both in terms of volume and experience) are the most obvious difference but there are many others as well. Many diagnostic tests are not as readily available during these times. Physician and consultant availability may be different and cross-coverage by physicians who lack detailed knowledge about individual patients is common. You also see more verbal orders, which of course are error-prone, at night and on weekends. But we’ve also argued that often it is a difference in non-clinical staffing that is a root cause. Our December 15, 2009 Patient Safety Tip of the Week “The Weekend Effect” discussed how adding non-clinical administrative tasks to already overburdened nursing staff on weekends may be detrimental to patient care. Just do rounds on one of your med/surg floors or ICU’s on a weekend. You’ll see nurses answering phones all day long, causing interruptions in some attention-critical nursing activities. Calls from radiology and the lab that might go directly to physicians now go first to the nurse on the floor, who then has to try to track down the physician. They end up filing lab and radiology reports or faxing medication orders down to pharmacy, activities often done by clerical staff during daytime hours. In those facilities that have CPOE, nurses off-hours often end up entering those orders into the computer because the physicians are off-site and are phoning in verbal orders. You’ll also see nurses giving directions to the increased numbers of visitors typically seen on weekends. Nurses even end up doing some housekeeping chores. All of these interruptions and distractions obviously interfere with nurses’ ability to attend to their clinically important tasks (see our Patient Safety Tips of the Week for August 25, 2009 “Interruptions, Distractions, Inattention…Oops!” and May 4, 2010 “More on the Impact of Interruptions”).

 

For surgery there are even other considerations. Not only might the surgeon and anesthesiologist be called in from other activities but the OR team of nurses and techs are also often called in from other activities. Often the surgeries are performed by teams that are not used to working together. Though we are unaware of any published studies on environmental issues that might impact the weekend effect, we suspect that there might be factors related to equipment, sterilization procedures, overall cleanliness, OR temperature and humidity, and others that conceivably might differ on weekends.

 

To fix many of the above potential contributing factors would obviously require considerable resources, both financial and human. In our November 2013 What’s New in the Patient Safety World column “The Weekend Effect: Not One Simple Answer” we made a business case that cases prone to the weekend effect are likely more costly to hospitals (eg. complications are usually associated with increased lengths of stay and utilization of more tests, medications, etc.). So there is likely a return on investment (ROI) for resources spent alleviating some of these factors.

 

The “weekend effect” is a complex one, not easily amenable to one solution.

 

 

 

Some of our previous columns on the “weekend effect:

·         February 26, 2008     Nightmares….The Hospital at Night

·         December 15, 2009   The Weekend Effect

·         July 20, 2010             More on the Weekend Effect/After-Hours Effect

·         October 2008             Hospital at Night Project

·         September 2009         After-Hours Surgery – Is There a Downside?

·         December 21, 2010   More Bad News About Off-Hours Care

·         June 2011                  Another Study on Dangers of Weekend Admissions

·         September 2011         Add COPD to Perilous Weekends

·         August 2012              More on the Weekend Effect

·         June 2013                  Oh No! Not Fridays Too!

·         November 2013         The Weekend Effect: Not One Simple Answer

 

 

 

References:

 

 

Goldstein SD, Papandria DJ, Aboagye J, Salazar JH, et al. The “weekend effect” in pediatric surgery — increased mortality for children undergoing urgent surgery during the weekend. Journal of Pediatric Surgery 2014; 49(7): 1087-1091 July 2014

http://www.jpedsurg.org/article/S0022-3468%2814%2900005-0/abstract

 

 

Concha OP, Gallego B, Hillman K, et al. Do variations in hospital mortality patterns after weekend admission reflect reduced quality of care or different patient cohorts? A population-based study.  BMJ Qual Saf 2013; published online 25 October 2013 doi:10.1136/bmjqs-2013-002218

http://qualitysafety.bmj.com/content/early/2013/10/22/bmjqs-2013-002218.full.pdf+html

 

 

 

 

 

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More Questions About Beta Blockers in MI

 

 

In our July 2014 What’s New in the Patient Safety World column “Issues on Timing of Beta Blockers in MI” we discussed a new analysis from the GRACE registry (Park 2014) that raised issues regarding the timing and route of administration of beta blockers in patients with ST-segment elevation MI (STEMI). But we also noted that studies had clearly demonstrated the long-term benefit of chronic beta blockers in patients with a history of MI and remained a mainstay in the treatment of patients who have had an MI.

 

Now even the latter practice has even come under scrutiny. A new meta-analysis was done on over 100,000 patients in randomized controlled trials of beta blockers after MI (Bangalore 2014). Importantly, the authors separated out the studies into the pre-reperfusion ear and the reperfusion era and found significant differences between the two timeframes. In the pre-reperfusion era beta-blockers were associated with a significant reduction in overall mortality as well as significant reductions in cardiovascular mortality, MI, and angina. In the reperfusion era there were still significant reductions in MI and angina with beta-blocker therapy but there was no overall mortality benefit. The reductions in MI and angina were balanced against increases in heart failure and cardiogenic shock. And even the benefit of reduced MI and angina appears to be limited to the period 30-days post-MI.

 

The authors recommend that clinical practice guidelines should reconsider the strength of recommendations for beta-blockers after myocardial infarction.

 

This may well result in yet another reversal of clinical practices which we had considered soundly “evidence-based” or practices that moved outside their originally researched clinical populations or settings. We’ve seen routine perioperative beta-blockers (for non-cardiac surgery) come and go. Prophylactic proton pump inhibitors gained widespread use outside ICU settings, only to have detrimental effects appear. Our push to mandate antibiotics within 4 hours for community-acquired pneumonia resulted in many patients without pneumonia being exposed unnecessarily to antibiotics. Intensive blood glucose control came and went for ICU patients. And these don’t even cover those things we mandated without a solid evidence base that continue to have unintended consequences pop up (eg. work hour restrictions, CPOE, etc.).

 

The Bangalore study is thus a good reminder that we need to have constant vigilance of even our most time-honored clinical practices to ensure that they are truly evidence-based, especially when other advances in medical care have occurred in the interim.

 

Even if the net benefit of beta-blockers after MI is neither positive nor negative, there are cost consequences to patients, hospitals, payors and society. Beta-blocker use in patients after MI is a core measure of most pay-for-performance and quality measurement programs and much time and effort is spent ensuring such patients get beta-blockers. The Bangalore group should be commended for questioning practices we’ve long felt did not need to be questioned. It will be very interesting to see whether practice guidelines are indeed reconsidered in view of the evidence they’ve presented.

 

 

One other area in which beta-blockers have often been used despite a weak evidence base is for patients with coronary heart disease without a history of prior MI. And another new analysis has further challenged that use as well (Andersson 2014). Those authors looked at over 26,000 consecutive patients discharged after a first coronary event (acute coronary syndrome or coronary revascularization) between 2000 and 2008 who had not previously been on beta-blockers. Beta-blockers were initiated within 7 days in over 19,000 of these patients. A lower risk of cardiac events with beta-blockers was seen only for patients with MI.

 

The accompanying editorial (Steg 2014), however, notes the Andersson study is limited by lack of data on clinical characteristics of the patients which may have influenced decisions about whether to use beta-blockers. Beta-blockers may, of course, be important in alleviation of angina in such patients so they likely will still have a role in some patients.

 

We suspect it is very unlikely that a randomized controlled trial of beta-blockers in either MI patients or those with other coronary syndromes will be done in the future. But the Bangalore and Andersson studies certainly raise awareness that the evidence base for such time-honored practices is far less hearty than most realize.

 

 

 

References:

 

 

Park KL, Goldberg RJ, Anderson FA, et al. Beta-blocker Use in ST-segment Elevation Myocardial Infarction in the Reperfusion Era (GRACE). Am J Med 2014; 127(6): 503–511

http://www.amjmed.com/article/S0002-9343%2814%2900140-5/fulltext

 

 

Bangalore S, Makani H, Radford M, et al. Clinical outcomes with beta-blockers for myocardial infarction. Am J Med 2014; DOI: http://dx.doi.org/10.1016/j.amjmed.2014.05.032 Published Online: June 10, 2014

http://www.amjmed.com/article/S0002-9343%2814%2900470-7/abstract

 

 

Andersson C, Shilane D, Go AS, et al. Beta-Blocker Therapy and Cardiac Events Among Patients With Newly Diagnosed Coronary Heart Disease. J Am Coll Cardiol 2014; 64(3): 247-252

http://content.onlinejacc.org/article.aspx?articleID=1889068

 

 

Steg PG, De Silva R. Beta-Blockers in Asymptomatic Coronary Artery DiseaseNo Benefit or No Evidence? J Am Coll Cardiol 2014; 64(3): 253-255

http://content.onlinejacc.org/article.aspx?articleID=1889069

 

 

 

 

 

 

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Cataract Surgery and Falls

 

 

Impaired vision is one factor that contributes to loss of balance and falls. So it seems logical that correction of vision should prevent falls. But in our What’s New in the Patient Safety World columns for June 2010 “Seeing Clearly a Common Sense Intervention” and June 2014 “New Glasses and Fall Risk” we noted that sometimes new glasses and correction of vision may paradoxically result in increased falls.

 

What about cataract surgery? How does it impact the risk of falls? A recent Australian study (Meuleners 2014) used large linked population databases to examine the possible relationship. The authors note that the previous literature on the impact of cataract surgery on falls is conflicting, with some studies showing a reduction in falls and some showing an increase in falls. They then addressed the risk of injurious falls requiring hospitalization in patients undergoing bilateral cataract surgery, which is typically done one eye at a time in Australia. Compared to the 2 years prior to surgery the risk of injurious falls requiring hospitalization was over twice as high (RR 2.14) between first- and second-eye cataract surgery. And there was still a 34% increase in injurious falls requiring hospitalization after the second-eye cataract surgery compared to the 2 years prior to surgery.

 

So what does this mean? One obvious problem is the before-after design of the study. What we don’t know are the before and after rates of injurious falls requiring hospitalization in patients with bilateral cataracts who did not have surgery (though even those rates would be subject to selection bias when compared to the rates in the current paper). The point is that we might very well anticipate an increase in the fall rate over time in this population, which is largely elderly and has multiple comorbidities, regardless of whether they have cataract surgery.

 

Also, we don’t know anything about the activities in these patients. The authors acknowledge that it is quite possible that patients with improved vision after cataract surgery become more active and may take risks they would not have previously taken and therefore increase their chances of a fall.

 

We have long been advocates of falls with injury being a more important measure than simple fall rates so we have no problem with the measures they chose. A randomized controlled trial to see whether cataract surgery reduces or increases falls with injury is very unlikely to ever happen. So we’ll probably never know for sure but have to presume that cataract surgery might possibly increase the risk of falls with injury.

 

But the main message of the study is that the period of time between surgeries is one in which the patients are particularly vulnerable to injurious falls requiring hospitalization. The authors recommend patients be informed of this risk and that ophthalmologists take into consideration the timeliness of the second eye surgery.

 

Cataract surgery clearly improves multiple aspects of vision and improves quality of life. So the message here is not to avoid cataract surgery but rather recognize that there could be an increased risk of serious falls, particularly in the period between surgeries.

 

Another example that even interventions having positive results may also have unintended consequences!

 

 

References:

 

 

Meuleners LB, Fraser ML, Ng J, Morlet N. The impact of first- and second-eye cataract surgery on injurious falls that require hospitalisation: a whole-population study. Age Ageing 2014; 43(3): 341-346

http://ageing.oxfordjournals.org/content/43/3/341.abstract

 

 

 

 

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A New Rapid Screen for Delirium in the Elderly

 

 

We’ve discussed the importance of recognizing delirium in multiple columns (see the list at the end of today’s column). Yet delirium goes unrecognized or undiagnosed in up to 72% of cases in hospitalized patients (Collins 2010). One of the reasons may be that commonly used screening tests for delirium may not be brief enough or may require specific training for administration.

 

So researchers have developed a new screening tool, the 4 ‘A’s’ Test (4AT) to help improve screening for delirium.

 

The 4AT tool has now been validated in a population other than that in which it was developed (Bellelli 2014). The authors note that the many of the currently used screening tools for delirium lack some of the following characteristics:

 

Bellelli and colleagues therefore administered the 4AT in 236 consecutive elderly patients admitted to an acute geriatrics ward or a post-acute rehabilitation unit. The CAM (Confusion Assessment Method) was used as the reference diagnostic standard and the DSM-IV-TR criteria used for diagnosis. Delirium was detected in 12.3%, dementia in 31.2%, and a combination of both in 7.2%. The 4AT had a sensitivity of 89.7% and specificity 84.1% for delirium. Specificity was higher in the subgroup without dementia, while sensitivity was higher in the group with dementia. The authors conclude that the 4AT is a sensitive and specific method of screening for delirium in hospitalized older people and that its brevity and simplicity support its use in routine clinical practice.

 

We recommend that, if you’ve been using a validated tool like the CAM and have been using it regularly to screen for delirium, you continue to use it. But if you have not been regularly screening for delirium, consider giving the 4AT a try. It’s simple and easy to administer and appears to be a reliable tool.

 

 

Some of our prior columns on delirium assessment and management:

·         October 21, 2008 “Preventing Delirium

·         October 14, 2009 “Managing Delirium

·         February 10, 2009 “Sedation in the ICU: The Dexmedetomidine Study

·         March 31, 2009 “Screening Patients for Risk of Delirium

·         June 23, 2009  More on Delirium in the ICU

·         January 26, 2010 “Preventing Postoperative Delirium

·         August 31, 2010 “Postoperative Delirium

·         September 2011 “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery

·         December 2010 “The ABCDE Bundle

·         February 28, 2012AACN Practice Alert on Delirium in Critical Care

·         April 3, 2012 “New Risk for Postoperative Delirium: Obstructive Sleep Apnea

·         August 7, 2012 “Cognition, Post-Op Delirium, and Post-Op Outcomes

·         September 2013 “Disappointing Results in Delirium

·         October 29, 2013 “PAD: The Pain, Agitation, and Delirium Care Bundle

·         February 2014 “New Studies on Delirium

·         March 25, 2014 “Melatonin and Delirium

·         May 2014 “New Delirium Severity Score

 

 

 

References:

 

 

Collins N, Blanchard MR, Tookman A, Sampson EL. Detection of delirium in the acute hospital. Age Ageing 2010; 39 (1): 131-135

http://ageing.oxfordjournals.org/content/39/1/131.full.pdf+html

 

 

The 4 ‘A’s Test: screening instrument for delirium and cognitive impairment

http://www.the4at.com/

 

 

Bellelli G, Morandi A, Davis DHJ, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing 2014; 43(4): 496-502

http://ageing.oxfordjournals.org/content/43/4/496.full.pdf+html

 

 

 

 

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Delirium in Pediatrics

 

 

Virtually all our columns on delirium screening, diagnosis and management have focused on adult patients, particularly the elderly. However, recently there has been an interest kindled in recognition of delirium in pediatric patients.

 

One research group conducted a survey of pediatric intensivists regarding sedation management, sleep promotion, and delirium screening practices for intubated and mechanically ventilated children (Kudchadkar 2014). They found that delirium screening was not practiced in 71% of respondent’s PICUs, and only 2% reported routine screening at least twice a day. Use of earplugs, eye masks, noise reduction, and lighting optimization for sleep promotion was uncommon. Only 27% of respondents reported having written sedation protocols. And though 70% of respondents worked in PICUs with sedation scoring systems, only 42% of those with access to scoring systems reported routine daily use for goal-directed sedation management. There was also considerable variation in the drugs used for sedation.

 

A viewpoint in the July issue of JAMA Pediatrics by Schieveld and Janssen (Schieveld 2014) called for growing recognition of pediatric delirium. Specifically, the authors recommend use of diagnostic criteria for pediatric delirium such as use of the Cornell Assessment of Pediatric Delirium tool (Traube 2014). The CAPD is a rapid observational screening tool recently validated in a pediatric ICU (PICU) setting and found to have an overall sensitivity of 94.1% and specificity of 79.2%. Interestingly, in their study population Traube and colleagues found the overall prevalence rate of delirium was 20.6%. So while not as high as the 60-80% prevalence typically seen in adult ICU’s, it is clear that delirium is a common problem in pediatric critical care. The viewpoint article (Schieveld 2014) also noted the importance of inclusion of developmental “anchor” points to help in screening of very young children or those with developmental delay and called for use of flowcharts and continuous monitoring for delirium in the pediatric ICU patients.

 

 

Some of our prior columns on delirium assessment and management:

·         October 21, 2008 “Preventing Delirium

·         October 14, 2009 “Managing Delirium

·         February 10, 2009 “Sedation in the ICU: The Dexmedetomidine Study

·         March 31, 2009 “Screening Patients for Risk of Delirium

·         June 23, 2009  More on Delirium in the ICU

·         January 26, 2010 “Preventing Postoperative Delirium

·         August 31, 2010 “Postoperative Delirium

·         September 2011 “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery

·         December 2010 “The ABCDE Bundle

·         February 28, 2012AACN Practice Alert on Delirium in Critical Care

·         April 3, 2012 “New Risk for Postoperative Delirium: Obstructive Sleep Apnea

·         August 7, 2012 “Cognition, Post-Op Delirium, and Post-Op Outcomes

·         September 2013 “Disappointing Results in Delirium

·         October 29, 2013 “PAD: The Pain, Agitation, and Delirium Care Bundle

·         February 2014 “New Studies on Delirium

·         March 25, 2014 “Melatonin and Delirium

·         May 2014 “New Delirium Severity Score

·         August 2014 “A New Rapid Screen for Delirium in the Elderly

 

 

 

 

 

References:

 

 

Kudchadkar SR, Yaster M, Punjabi NM. Sedation, Sleep Promotion, and Delirium Screening Practices in the Care of Mechanically Ventilated Children: A Wake-Up Call for the Pediatric Critical Care Community. Crit Care Med 2014; 42(7): 1592-1600

http://journals.lww.com/ccmjournal/Abstract/2014/07000/Sedation,_Sleep_Promotion,_and_Delirium_Screening.2.aspx

 

 

Schieveld JNM, Janssen NJJF. Delirium in the Pediatric Patient. On the Growing Awareness of Its Clinical Interdisciplinary Importance. JAMA Pediatrics 2014; 168(7): 595-596

http://archpedi.jamanetwork.com/article.aspx?articleid=1867336

 

 

Traube C, Silver G, Kearney J, et al. Cornell Assessment of Pediatric Delirium: A Valid, Rapid, Observational Tool for Screening Delirium in the PICU. Critical Care Medicinem 2014; 42(3):656-663

http://journals.lww.com/ccmjournal/Abstract/2014/03000/Cornell_Assessment_of_Pediatric_Delirium__A_Valid,.20.aspx

 

 

 

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