FHM

Clinical question: Among patients with septic shock undergoing mechanical ventilation, does hydrocortisone reduce 90-day mortality?

Background: Septic shock is associated with a significant mortality risk, and there is no proven pharmacologic treatment other than fluids, vasopressors, and antimicrobials. Prior randomized, controlled trials have resulted in mixed outcomes, and meta-analyses and clinical practice guidelines also have not provided consistent guidance.

Study design: Randomized, controlled, double-blinded trial.

Setting: Medical centers in Australia, Denmark, New Zealand, Saudi Arabia, and the United Kingdom.

Synopsis: Over a 4-year period from 2013 to 2017, 3,658 patients with septic shock undergoing mechanical ventilation were randomized to receive either a continuous infusion of 200 mg/day of hydrocortisone for 7 days or placebo. The primary outcome, death within 90 days, occurred in 511 patients (27.9%) in the hydrocortisone group and in 526 patients (28.8%) in the placebo group (P = .50).

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Clinical question: Among patients with septic shock undergoing mechanical ventilation, does hydrocortisone reduce 90-day mortality?

Background: Septic shock is associated with a significant mortality risk, and there is no proven pharmacologic treatment other than fluids, vasopressors, and antimicrobials. Prior randomized, controlled trials have resulted in mixed outcomes, and meta-analyses and clinical practice guidelines also have not provided consistent guidance.

Study design: Randomized, controlled, double-blinded trial.

Setting: Medical centers in Australia, Denmark, New Zealand, Saudi Arabia, and the United Kingdom.

Synopsis: Over a 4-year period from 2013 to 2017, 3,658 patients with septic shock undergoing mechanical ventilation were randomized to receive either a continuous infusion of 200 mg/day of hydrocortisone for 7 days or placebo. The primary outcome, death within 90 days, occurred in 511 patients (27.9%) in the hydrocortisone group and in 526 patients (28.8%) in the placebo group (P = .50).

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Clinical question: Among patients with septic shock undergoing mechanical ventilation, does hydrocortisone reduce 90-day mortality?

Background: Septic shock is associated with a significant mortality risk, and there is no proven pharmacologic treatment other than fluids, vasopressors, and antimicrobials. Prior randomized, controlled trials have resulted in mixed outcomes, and meta-analyses and clinical practice guidelines also have not provided consistent guidance.

Study design: Randomized, controlled, double-blinded trial.

Setting: Medical centers in Australia, Denmark, New Zealand, Saudi Arabia, and the United Kingdom.

Synopsis: Over a 4-year period from 2013 to 2017, 3,658 patients with septic shock undergoing mechanical ventilation were randomized to receive either a continuous infusion of 200 mg/day of hydrocortisone for 7 days or placebo. The primary outcome, death within 90 days, occurred in 511 patients (27.9%) in the hydrocortisone group and in 526 patients (28.8%) in the placebo group (P = .50).

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Clinical question: Does prompting hospitalists during interdisciplinary rounds to discontinue lab orders on patients nearing discharge result in a decrease in lab testing?

Background: The Society of Hospital Medicine, as part of the Choosing Wisely campaign, has recommended against “repetitive complete blood count and chemistry testing in the face of clinical and lab stability.” Repeated phlebotomy has been shown to increase iatrogenic anemia and patient discomfort. While past interventions have been effective in decreasing lab testing, this study focused on identifying and intervening on patients who were clinically stable and nearing discharge.

Study design: Prospective, observational study.

Setting: Tertiary care teaching hospital in New York.

Synopsis: As part of structured, bedside, interdisciplinary rounds, over the course of a year, this study incorporated an inquiry to identify patients who were likely to be discharged in the next 24-48 hours; the unit medical director or nurse manager then prompted staff to discontinue labs for these patients when appropriate. This was supplemented by education of clinicians and regular review of lab utilization data with hospitalists.

The percentage of patients with labs ordered in the 24 hours prior to discharge decreased from 50.1% in the preintervention period to 34.5% in the postintervention period (P = .004). The number of labs ordered per patient-day dropped from 1.96 to 1.83 (P = .01).

Bottom line: An intervention with prompting during structured interdisciplinary rounds decreased the frequency of labs ordered for patients nearing hospital discharge.

Citation: Tsega S et al. Bedside assessment of the necessity of daily lab testing for patients nearing discharge. J Hosp Med. 2018 Jan 1;13(1):38-40.
 

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Clinical question: Does prompting hospitalists during interdisciplinary rounds to discontinue lab orders on patients nearing discharge result in a decrease in lab testing?

Background: The Society of Hospital Medicine, as part of the Choosing Wisely campaign, has recommended against “repetitive complete blood count and chemistry testing in the face of clinical and lab stability.” Repeated phlebotomy has been shown to increase iatrogenic anemia and patient discomfort. While past interventions have been effective in decreasing lab testing, this study focused on identifying and intervening on patients who were clinically stable and nearing discharge.

Study design: Prospective, observational study.

Setting: Tertiary care teaching hospital in New York.

Synopsis: As part of structured, bedside, interdisciplinary rounds, over the course of a year, this study incorporated an inquiry to identify patients who were likely to be discharged in the next 24-48 hours; the unit medical director or nurse manager then prompted staff to discontinue labs for these patients when appropriate. This was supplemented by education of clinicians and regular review of lab utilization data with hospitalists.

The percentage of patients with labs ordered in the 24 hours prior to discharge decreased from 50.1% in the preintervention period to 34.5% in the postintervention period (P = .004). The number of labs ordered per patient-day dropped from 1.96 to 1.83 (P = .01).

Bottom line: An intervention with prompting during structured interdisciplinary rounds decreased the frequency of labs ordered for patients nearing hospital discharge.

Citation: Tsega S et al. Bedside assessment of the necessity of daily lab testing for patients nearing discharge. J Hosp Med. 2018 Jan 1;13(1):38-40.
 

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Clinical question: Does prompting hospitalists during interdisciplinary rounds to discontinue lab orders on patients nearing discharge result in a decrease in lab testing?

Background: The Society of Hospital Medicine, as part of the Choosing Wisely campaign, has recommended against “repetitive complete blood count and chemistry testing in the face of clinical and lab stability.” Repeated phlebotomy has been shown to increase iatrogenic anemia and patient discomfort. While past interventions have been effective in decreasing lab testing, this study focused on identifying and intervening on patients who were clinically stable and nearing discharge.

Study design: Prospective, observational study.

Setting: Tertiary care teaching hospital in New York.

Synopsis: As part of structured, bedside, interdisciplinary rounds, over the course of a year, this study incorporated an inquiry to identify patients who were likely to be discharged in the next 24-48 hours; the unit medical director or nurse manager then prompted staff to discontinue labs for these patients when appropriate. This was supplemented by education of clinicians and regular review of lab utilization data with hospitalists.

The percentage of patients with labs ordered in the 24 hours prior to discharge decreased from 50.1% in the preintervention period to 34.5% in the postintervention period (P = .004). The number of labs ordered per patient-day dropped from 1.96 to 1.83 (P = .01).

Bottom line: An intervention with prompting during structured interdisciplinary rounds decreased the frequency of labs ordered for patients nearing hospital discharge.

Citation: Tsega S et al. Bedside assessment of the necessity of daily lab testing for patients nearing discharge. J Hosp Med. 2018 Jan 1;13(1):38-40.
 

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Background: ABM is a diagnosis with high morbidity and mortality. Early antimicrobial and corticosteroid therapy is beneficial. Current practice tends to defer LP prior to imaging when there is potential risk of herniation. Sweden’s guidelines for getting a CT scan prior to LP differ substantially from the Infectious Disease Society of America (IDSA), which recommends obtaining CT in patients with immunocompromised state, history of CNS disease, or impaired mental status.

Study design: Prospective cohort study.

Setting: 815 adult patients (older than 16 years old) in Sweden with confirmed acute bacterial meningitis.

Synopsis: The authors looked at adherence to guidelines for when to obtain a CT prior to LP, as well as compared mortality and neurologic outcomes when an LP was performed promptly versus when delayed for prior neuroimaging. CT neuroimaging was required in much smaller populations under Swedish guidelines (7%), compared with IDSA (65%), with improved mortality and outcomes in patients managed with the Swedish guidelines. Mortality was lower in patients who had a prompt LP than for those who got CT prior to the LP (4% vs. 10%). This mortality benefit was seen even in patients with immunocompromised state or altered mental status, confirming that earlier administration of appropriate therapy is associated with lower mortality. A major limitation is that the study included patients with confirmed meningitis rather than more clinically relevant cases of suspected bacterial meningitis.

Bottom line: Patients with suspected bacterial meningitis should have appropriate antimicrobial and corticosteroid therapy started as soon as possible, regardless of the decision to obtain CT scan prior to performing lumbar puncture.

Citation: Glimaker M et al. Lumbar puncture performed promptly or after neuroimaging in acute bacterial meningitis in adults: a prospective national cohort study evaluating different guidelines. Clin Infect Dis. 2017 Sep 9. doi: 10.1093/cid/cix806 (epub ahead of print).

Dr. Maleque is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.

Background: ABM is a diagnosis with high morbidity and mortality. Early antimicrobial and corticosteroid therapy is beneficial. Current practice tends to defer LP prior to imaging when there is potential risk of herniation. Sweden’s guidelines for getting a CT scan prior to LP differ substantially from the Infectious Disease Society of America (IDSA), which recommends obtaining CT in patients with immunocompromised state, history of CNS disease, or impaired mental status.

Study design: Prospective cohort study.

Setting: 815 adult patients (older than 16 years old) in Sweden with confirmed acute bacterial meningitis.

Synopsis: The authors looked at adherence to guidelines for when to obtain a CT prior to LP, as well as compared mortality and neurologic outcomes when an LP was performed promptly versus when delayed for prior neuroimaging. CT neuroimaging was required in much smaller populations under Swedish guidelines (7%), compared with IDSA (65%), with improved mortality and outcomes in patients managed with the Swedish guidelines. Mortality was lower in patients who had a prompt LP than for those who got CT prior to the LP (4% vs. 10%). This mortality benefit was seen even in patients with immunocompromised state or altered mental status, confirming that earlier administration of appropriate therapy is associated with lower mortality. A major limitation is that the study included patients with confirmed meningitis rather than more clinically relevant cases of suspected bacterial meningitis.

Bottom line: Patients with suspected bacterial meningitis should have appropriate antimicrobial and corticosteroid therapy started as soon as possible, regardless of the decision to obtain CT scan prior to performing lumbar puncture.

Citation: Glimaker M et al. Lumbar puncture performed promptly or after neuroimaging in acute bacterial meningitis in adults: a prospective national cohort study evaluating different guidelines. Clin Infect Dis. 2017 Sep 9. doi: 10.1093/cid/cix806 (epub ahead of print).

Dr. Maleque is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.

Background: ABM is a diagnosis with high morbidity and mortality. Early antimicrobial and corticosteroid therapy is beneficial. Current practice tends to defer LP prior to imaging when there is potential risk of herniation. Sweden’s guidelines for getting a CT scan prior to LP differ substantially from the Infectious Disease Society of America (IDSA), which recommends obtaining CT in patients with immunocompromised state, history of CNS disease, or impaired mental status.

Study design: Prospective cohort study.

Setting: 815 adult patients (older than 16 years old) in Sweden with confirmed acute bacterial meningitis.

Synopsis: The authors looked at adherence to guidelines for when to obtain a CT prior to LP, as well as compared mortality and neurologic outcomes when an LP was performed promptly versus when delayed for prior neuroimaging. CT neuroimaging was required in much smaller populations under Swedish guidelines (7%), compared with IDSA (65%), with improved mortality and outcomes in patients managed with the Swedish guidelines. Mortality was lower in patients who had a prompt LP than for those who got CT prior to the LP (4% vs. 10%). This mortality benefit was seen even in patients with immunocompromised state or altered mental status, confirming that earlier administration of appropriate therapy is associated with lower mortality. A major limitation is that the study included patients with confirmed meningitis rather than more clinically relevant cases of suspected bacterial meningitis.

Bottom line: Patients with suspected bacterial meningitis should have appropriate antimicrobial and corticosteroid therapy started as soon as possible, regardless of the decision to obtain CT scan prior to performing lumbar puncture.

Citation: Glimaker M et al. Lumbar puncture performed promptly or after neuroimaging in acute bacterial meningitis in adults: a prospective national cohort study evaluating different guidelines. Clin Infect Dis. 2017 Sep 9. doi: 10.1093/cid/cix806 (epub ahead of print).

Dr. Maleque is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.