We don’t endorse vendors or products in our columns. But we
recently happened to come across an article written by a company COO that
highlighted a type of product sorely needed.
In our September 1, 2015 Patient Safety Tip of the Week “Smarter
Checklists” we were describing how we would develop a smart checklist for intrahospital transports. In that we included the following
statement: “Conceivably, the amount of oxygen remaining in the oxygen cylinder
might be populated in the checklist automatically via Bluetooth or other
wireless technology.” That is because oxygen runs out in a substantial number
of intrahospital transports (not just the transport
but also the stay in the area to which the transport occurred, such as
radiology). Because manually checking the gauge on the oxygen canister is often
a forgotten step before transporting patients, it would be useful to have a
technological tool that flags inadequate oxygen supplies.
Also, in our August 11, 2015 Patient Safety Tip of the Week
“New
Oxygen Guidelines: Thoracic Society of Australia and NZ” we noted that one
of the items we often check on Patient Safety Walk Rounds is the status of
oxygen cylinders wherever they may be stored. You’d be surprised how often we
find used (empty or partially empty) oxygen cylinders interspersed with full
ones. Obviously, that is a serious patient safety vulnerability since one can
readily see how in an emergency someone might grab an empty cylinder thinking
it is full of oxygen.
The article we recently came across (McSheffrey
2016) describes use of electronic notification technology to deliver
real-time alerts about oxygen cylinder status. We have not done a search to see
what other similar products might be out there. But it is nice to see that such
potential safeguards are now available.
Nevertheless, we do have a couple caveats about use of such
potential electronic notification technologies. One is that most rely on
battery power (or at least battery backup) and batteries may run low (see our
February 4, 2014 Patient Safety Tip of the Week “But
What If the Battery Runs Low?” for examples of problems that might arise
when batteries run low). Another potential problem is that methods of electronic
communication (Bluetooth, Wi-Fi, etc.) may not work in
all locations. And, most importantly, complacency may become an issue in that
staff may presume the oxygen cylinder is full because they have not received a
notification that it is not.
But the capability of electronically conveying the status of
oxygen cylinders is potentially very useful for patient safety purposes.
References:
McSheffrey M. Simplifying oxygen
tank monitoring. Long Term Living Magazine. 2016; October 3, 2016
http://www.ltlmagazine.com/article/rehabtherapy/simplifying-oxygen-tank-monitoring
Print “November
2016 Oxygen Tank Monitoring”
We’ve long been
advocates of using oxygen therapy wisely, using it only in patients with documented
hypoxemia and titrating it to appropriate oxygenation targets without producing
hyperoxemia. We’ve detailed in multiple columns the
potential downsides of hyperoxemia (see list at the
end of today’s column).
A new study (Girardis 2016)
randomized ICU patients to “conventional” care (where oxygen therapy was used
to achieve SpO2 levels 97-100%) or “conservative” oxygen therapy (where oxygen
therapy was titrated to target SpO2 levels of 94-98%). ICU mortality in the
conservative group was 11.6% compared to 20.2% in the conventional group, a
relative risk reduction of 57% and absolute risk reduction of 8.6%! Total
hospital mortality was also significantly lower in the conservative group.
Patients in the conservative group also had fewer episodes of shock, liver
failure, and bacteremia.
Sounds great, doesn’t it? While the reported results showed
a lower ICU mortality for patients in the conservative group, various aspects
of the study raise many questions, appropriately brought out in the
accompanying editorial (Ferguson 2016).
First of all, there were differences in the illness severity of patients at baseline,
favoring the conservative group so some of the lower mortality in that group
may have been due to lower severity of illness. Secondly, the trial was terminated
early, purportedly because of difficulty recruiting patients and because the
interim results so strongly favored the conservative group. Clinical trials
that are terminated early tend to overestimate the treatment effect. Thirdly,
the modified intention-to-treat analysis used excluded patients who were
randomized but did not remain in the ICU for at least 72 hours and those who
did not have at least one ABG analysis per day. And, though differences in
deaths were statistically significant, the total number of deaths was small.
And this was a single center study so generalization may not be appropriate.
Botom line: these results need to
be validated in another (preferably multicenter) trial of sufficient size with
appropriate randomization. But while we are waiting for such a study, we concur
with the editorialist that careful titration of oxygen therapy to achieve
physiologically normal levels and avoid hyperoxia
makes sense.
Some of our prior
columns on potential harmful effects of oxygen:
April 8, 2008 “Oxygen
as a Medication”
January 27, 2009 “Oxygen
Therapy: Everything You Wanted to Know and More!”
April 2009 “Nursing
Companion to the BTS Oxygen Therapy Guidelines”
October 6, 2009 “Oxygen
Safety: More Lessons from the UK”
July 2010 “Cochrane
Review: Oxygen in MI”
December 6, 2011 “Why
You Need to Beware of Oxygen Therapy”
February 2012 “More
Evidence of Harm from Oxygen”
March 2014 “Another
Strike Against Hyperoxia”
June 17, 2014 “SO2S
Confirms Routine O2 of No Benefit in Stroke”
December 2014 “Oxygen
Should Be AVOIDed”
August 11, 2015 “New
Oxygen Guidelines: Thoracic Society of Australia and NZ”
References:
Girardis M, Busani
S, Damiani E, et al. Effect of Conservative vs
Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care UnitThe Oxygen-ICU Randomized Clinical Trial. JAMA 2016;
Online First October 5, 2016
http://jama.jamanetwork.com/article.aspx?articleid=2565306
Ferguson ND. Oxygen in the ICU. Too Much of a Good Thing? JAMA 2016; Published online October
05, 2016
http://jama.jamanetwork.com/article.aspx?articleid=2565302
Print “November
2016 More on Safer Use of Oxygen”
We’ve done numerous
columns over the years about the increasing evidence that more restrictive
criteria for transfusions do not lead to worse outcomes for many or even most
patient conditions and that transfusions may be associated with a variety of
potential adverse effects. The AABB (American Association of Blood Banks)
updated its guidelines on transfusion in 2012 (see our April 2012 What's New in the Patient Safety World column “New
Transfusion Guidelines from the AABB”) to reflect the trending literature.
Now the AABB has once again updated its transfusion guidelines after reviewing
the updated literature for randomized controlled trials (RCT’s) dealing with
transfusion criteria (Carson
2016).
The updated AABB
guideline recommends two tiers of hemoglobin level transfusion triggers:
The guidelines do
not include any recommendations regarding patients with acute coronary
syndromes, severe thrombocytopenia, or chronic transfusion–dependent anemia.
Interestingly, one
point brought out in the discussion is that "standard practice should be
to initiate a transfusion with 1 unit of blood rather than 2 units. This would
have potentially important implications for the use of blood transfusions and
minimize the risks of infectious and noninfectious complications”. That is of interest because one of the
triggers historically used by transfusion committees to review cases for appropriateness
was the use of a single unit of packed RBC’s rather than at least two units.
The other new
recommendation has to do with the freshness of the RBC’s. It states that patients,
including neonates, should receive RBC units selected at any point within their
licensed dating period rather than limiting patients to transfusion of only
fresh (storage length: <10 days) RBC units.
The Carson article
also includes the evidence summary and has a nice table summarizing the odds of
the various adverse effects of RBC transfusions.
In an accompanying
editorial (Yazer 2016)
Yazer and Triulzi remind us
that good clinical practice dictates
that the decision to transfuse should not be solely based on the hemoglobin
level. They suggest that future studies look at inclusion of some sort of
measure of tissue oxygenation to aid in the clinical decision about
transfusion.
The Carson article
includes the following Good Clinical Practice Statement: “When deciding to
transfuse an individual patient, it is good practice to consider not only the
hemoglobin level, but the overall clinical context and alternative therapies to
transfusion. Variables to take into consideration include the rate of decline
in hemoglobin level, intravascular volume status, shortness of breath, exercise
tolerance, lightheadedness, chest pain thought to be cardiac in origin,
hypotension or tachycardia unresponsive to fluid challenge, and patient
preferences. This practice guideline is not intended as an absolute standard and
will not apply to all individual transfusion decisions.”
Prior columns on
potential detrimental effects related to red blood cell transfusions:
References:
Carson JL, Guyatt G, Heddle NM, et
al. Clinical Practice Guidelines from the AABB. Red Blood Cell Transfusion
Thresholds and Storage. JAMA 2016; Published online October 12, 2016
http://jamanetwork.com/journals/jama/article-abstract/2569055
Yazer MH, Triulzi
DJ. AABB Red Blood Cell Transfusion Guidelines. Something for Almost Everyone.
JAMA 2016; Published online October 12, 2016
http://jamanetwork.com/journals/jama/fullarticle/2569053
Print “November
2016 AABB Updates Transfusion Guidelines Again”
A recent study demonstrated that C. diff infections can
occur even in patients who have not received antibiotics if the patient
occupying their room previously had received antibiotics (Freedberg
2016). The authors found that subsequent patients were 22 percent
more likely to develop C. diff infections if the patient who previously occupied
their hospital bed had received antibiotics. It is likely that in patients
colonized with C. diff, antibiotic use may increase proliferation of the
bacterium, increasing the number of C. diff spores that make into the
environment.
So what does this
study mean in practical terms? Clearly, a patient is not going to be able to
ask whether the previous occupant of that room received antibiotics (in fact,
answering such question could probably be considered a HIPAA violation even if
the name of that patient were not revealed in the answer!). And, while it could
be considered an indictment of our inability to rid the environment of C. diff
spores, the real implication is that we need more focus on antibiotic
stewardship. See the list below of our prior columns on antibiotic stewardship.
Medscape recently
had a succinct review by John Bartlett on both the evidence base for antibiotic
stewardship practices and appropriate antibiotic prescribing practices for
common outpatient conditions (Bartlett
2016). He cited the recent guidelines from the Infectious Diseases
Society of America and Society for Healthcare Epidemiology of America (Barlam
2016) which showed that of 23
antibiotic stewardship interventions reviewed only 5 should be considered
endorsed recommendations with adequate supporting evidence:
Hopefully, the recent focus on antibiotic stewardship by CDC
and CMS and The Joint Commission will begin to have an impact not only on C.
diff infections but a whole host of adverse consequences of inappropriate
antibiotic use.
Some of our prior
columns on antibiotic stewardship:
References:
Freedberg DE, Salmasian
H, Cohen B, et al. Receipt of Antibiotics in Hospitalized Patients and Risk for
Clostridium difficile Infection in Subsequent Patients Who Occupy the Same Bed.
JAMA Intern Med 2016; Published online October 10, 2016
http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2565687
Bartlett JG. Antibiotic Stewardship Priorities: Follow the
Evidence. Medscape Infectious Disease 2016; October 12, 2016
http://www.medscape.com/viewarticle/870002?src=wnl_edit_tpal&uac=14695HV
Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship
program: guidelines by the Infectious Diseases Society of America and Society
for Healthcare Epidemiology of America. Clin Infect
Dis 2016; 62: e51-e77
http://cid.oxfordjournals.org/content/62/10/e51.full?sid=88b5b2fa-989f-4b15-9d02-8101b2760c30
Print “November
2016 C. Diff and Your Predecessor’s Room”
Print “November
2016 What's New in the Patient Safety World (full
column)”
Print “November
2016 Oxygen Tank Monitoring”
Print “November
2016 More on Safer Use of Oxygen”
Print “November
2016 AABB Updates Transfusion Guidelines Again”
Print “November
2016 C. Diff and Your Predecessor’s Room”
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