Hospital Consult - March 2016
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Worldwide Study: ARDS Often Unrecognized, Inadequately Treated in ICUs
TORONTO -- Acute respiratory distress syndrome (ARDS) might be quite common, affecting more than 10% of intensive care patients around the world, but the deadly condition also is under-recognized and undertreated, according to a large study.
The research involving more than 450 ICUs in 50 countries on five continents was published recently in JAMA.
"We know that 40% of patients with ARDS die, either of this syndrome or their primary illness or injury, so this new, global understanding of this important public health issue and how we are treating it is enormously important for patients and clinicians," said lead author John Laffey, MD, chief anesthesiologist at St. Michael's Hospital in Toronto.
In ARDS, an uncontrolled inflammatory response damages the lining of the lungs, causing fluid to build up in the alveoli, reducing the amount of oxygen that reaches the bloodstream and usually requiring the use of artificial ventilation, according to background information in the article.
For the LUNG SAFE (Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE) study, conducted by the European Society of Intensive Care Medicine, enrolled 29,144 patients admitted to 459 ICUs in 2014. While 10.4% of ICU patients developed ARDS, about six patients per ICU bed per year, many – 40% -- were not diagnosed.
Mortality rates varied by severity of the condition, with 34%, 40.3% and 46.1% dying of mild, moderate and severe ARDS, respectively, according to the report.
Part of the problem, according to Laffey, is that no single test exists for diagnosing a syndrome made up of many symptoms.
The study also found the following:
- Clinical recognition of ARDS ranged from 51.3% in mild to 78.5% in severe ARDS.
- Less than two-thirds of patients with ARDS received a tidal volume 8 of mL/kg or less of predicted body weight.
- Plateau pressure was measured in 40.1% patients, although 82.6% received a positive end-expository pressure (PEEP) of less than 12 cm H2O.
- Prone positioning was used in 16.3% of patients with severe ARDS, even though that improves oxygenation.
The study also cited geographic differences in the recognition and treatment of ARDS, although those were not as large as they expected. The highest incidence of ARDS was in Australia and New Zealand, followed by Europe and North America, according to the report.
“This syndrome appeared to be under-recognized and undertreated and associated with a high mortality rate,” study authors said. “These findings indicate the potential for improvement in the management of patients with ARDS.”
Use of Probiotics to Treat C. Difficile Increasing in Inpatients
ATLANTA – The jury is still out on whether probiotics effectively preserve or restore a healthy microbiome.
A trend toward increasing use of probiotics among hospitalized patients, however, suggests that many clinicians believe the agents might be helpful in treating Clostridium difficile infection (CDI), according to new research.
A descriptive study of 145 U.S. hospitals, published recently in the American Journal of Infection Control, finds that more patients are receiving probiotics as part of their inpatient hospital care. That is especially the case when hospitalized patients are diagnosed with CDI, which often is associated with a disrupted or damaged microbiome, according to researchers from the national Centers for Disease Control and Prevention’s Division of Healthcare Quality Promotion.
The study found that, in 2012, probiotics – most often Saccharomyces and Lactobacillus -- were used in 2.6% of hospitalizations and 96% of the healthcare centers in the sample, representing 51,724 hospitalizations.
Results also indicate that patients receiving probiotics were nine times more likely to receive antimicrobials and 21 times more likely to have a Clostridium difficile infection diagnosis. The article reports that 32% of patients treated with probiotics received Saccharomyces boulardii, 30% received Lactobacillus acidophilus and Lactobacillus bulgaricus, 28% received L acidophilus and 11% received Lactobacillus rhamnosus.
Overall, probiotic use increased from 1.0% of 1,090,373 discharges in 2006 to 2.9% of 1,006,051 discharges in 2012, according to the report.
“In this sample of U.S. hospitals, a sizable and growing number of inpatients received probiotics as part of their care despite inadequate evidence to support their use in this population,” study authors conclude. “Additional research is needed to guide probiotic use in the hospital setting.”
For clinicians intent on using the products, the CDC researchers urge being wary of product-labeling inaccuracies at the species, and even genus level, for reasons such as difficulty in identification, desire for consumer recognition and cross-contamination during manufacturing as well as varying susceptibility of strains to antibiotics, and product viability at the time of ingestion.
“The general questions needing to be answered include the following: Which strain-specific organisms, which patient populations, at what doses, and in what time frames (related to antibiotic use in particular) are both safe and effective in the prevention or treatment of which diseases?” they add.
Readmissions Reduced When Patients Sent Home with Medications
BOSTON – When patients hospitalized for asthma exacerbations fail to fill discharge prescriptions, hospitals often see them again, either as emergency department patients or readmissions.
The challenge taken on by a research team from Boston University and Boston Medical Center was to increase the proportion of patients discharged from an asthma admission in possession of their medications – i.e., “meds in hand” -- from a baseline of 0% to greater than 75%.
For the report published recently in Pediatrics, study authors conducted an exploratory, retrospective analysis of insurance data with a sample of Medicaid-insured patients. Post-discharge medication adherence between patients discharged with meds in hand and usual care were compared.
Among the changes to the discharge process was a service whereby outpatient pharmacists delivered medications to patient rooms. That immediately met the goal of 75% of patients leaving the hospital with meds in hand.
In a subset of patients for whom all insurance claims were available, researchers found that those discharged with meds in hand had lower odds of all-cause re-presentation to the ED within 30 days of discharge, compared with patients discharged with usual care.
“Our initiative led to several discharge process improvements, including the creation of a medication delivery service that increased the proportion of patients discharged in possession of their medications and may have decreased unplanned visits after discharge,” the authors point out.
Another study last year found that the number of discharge medications is associated with the prevalence of 30-day hospital readmission.
Writing in BMC Health Services Research, a Washington University-led study team reported that a risk score including the number of discharge medications can accurately predict patients at risk of readmission.
“Our findings suggest that relatively simple and accessible parameters can identify patients at high risk for hospital readmission potentially distinguishing such individuals for interventions to minimize readmissions,” study authors wrote.
Specific Factors Increase Bowel Obstruction Risk in Stroke Inpatients
KANSAS CITY, MO – Which hospitalized ischemic stroke patients are at the highest risk of developing bowel obstruction?
A presentation at the recent American Stroke Association's International Stroke Conference 2016 in Los Angeles provided an answer: Being older, black, and having pre-existing illnesses, such as cancer, all significantly increase the likelihood of the complication.
To better define which hospitalized stroke patients are most at risk of bowel obstruction, University of Missouri Kansas City School of Medicine researchers analyzed a national database of patients hospitalized for acute ischemic stroke from 2002 to 2011 and identified those who also had a diagnosis of bowel obstruction.
Their results indicate that, of the 3,988,667 patients hospitalized for ischemic stroke and identified in the Nationwide Inpatient Sample from 2002-2011, nearly 17,000 had bowel obstruction and 4.2% of them needed repair surgery for intestinal obstruction.
The study notes that factors increasing risk of bowel obstruction include:
- Advanced age, with stroke patients who were 75 years or older having almost twice the risk of patients younger than 55.
- Race, with black stroke patients having a 42% higher risk than white stroke patients.
- Co-morbidities and polypharmacy, with patients having pre-existing illnesses, such as cancer, and taking medications also having an elevated risk.
Being able to identify hospitalized stroke patients likely to develop bowel obstruction is critical because that also makes them more likely to develop deep vein thrombosis, pulmonary embolism, sepsis, acute kidney injury, gastrointestinal hemorrhage, and require blood transfusions, according to the report.
Researchers suggest some of those conditions resulted from increased hospital lengths-of-stay. The occurrence of bowel obstruction in hospitalized stroke patients increased hospital stay and costs by an average of 9.7 days and $22,342, according to the presentation.
The researchers also point out that, compared to ischemic stroke patients without bowel obstruction, those with the condition were nearly three times more likely to suffer moderate to severe disability and 39% more likely to die while inpatients.
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