J. Daniel Markley, DO

Clinical question: How does timing of surgical antibiotic prophylaxis affect risk of postoperative surgical-site infections (SSIs)?

Background: Antibiotic prophylaxis for major surgical procedures has been proven in clinical trials to reduce rates of SSI. The Centers for Medicare & Medicaid Services’ (CMS) Surgical Care Improvement Project (SCIP) has implemented quality metrics to ensure antibiotics are administered within 60 minutes of incision; however, studies have failed to show that a 60-minute pre-incision window is advantageous.

Study design: Retrospective cohort.

Setting: Veterans Affairs hospitals.

Synopsis: Using SCIP and VA Surgical Quality Improvement Program data from 112 VA hospitals, 32,459 cases of hip or knee arthroplasty, colorectal surgery, arterial vascular surgery, and hysterectomy from 2005 to 2009 were reviewed. A post-operative SSI occurred in 1,497 cases (4.6%). Using several statistical methods, the relationship between timing of prophylactic antibiotic administration and postoperative SSI within 30 days was evaluated.

In unadjusted models, higher SSI rates were observed with antibiotic administration more than 60 minutes prior to incision (OR 1.34, 95% CI 1.08-1.66) but not after incision (OR 1.26, 95% CI 0.92-1.72), compared with procedures with antibiotics administered within 60 minutes pre-incision. However, after adjustment for patient, procedure, and antibiotic variables, no significant relationship between timing and SSI was observed (P=0.50 for all specialties).

The study sample was comprised primarily of older men and did not include patients who underwent cardiac procedures, limiting the generalizability of the findings. Nonetheless, the study is the largest of its kind and confirms previous studies that suggest there is no significant relationship between timing of antibiotics and SSI. Prophylactic antibiotics should still be used when indicated; however, using timing of prophylactic antibiotics as a quality measure is unlikely to improve outcomes.

Bottom line: Adherence to the empiric 60-minute window metric for timing of prophylactic antibiotics is not significantly associated with risk of SSI.

Citation: Hawn MT, Richman JS, Vick CC, et al. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg. 2013 March 20:1-8. doi: 10.1001/jamasurg.2013.134 [Epub ahead of print].

Visit our website for more physician reviews of recent HM-relevant literature.

Clinical question: How does timing of surgical antibiotic prophylaxis affect risk of postoperative surgical-site infections (SSIs)?

Background: Antibiotic prophylaxis for major surgical procedures has been proven in clinical trials to reduce rates of SSI. The Centers for Medicare & Medicaid Services’ (CMS) Surgical Care Improvement Project (SCIP) has implemented quality metrics to ensure antibiotics are administered within 60 minutes of incision; however, studies have failed to show that a 60-minute pre-incision window is advantageous.

Study design: Retrospective cohort.

Setting: Veterans Affairs hospitals.

Synopsis: Using SCIP and VA Surgical Quality Improvement Program data from 112 VA hospitals, 32,459 cases of hip or knee arthroplasty, colorectal surgery, arterial vascular surgery, and hysterectomy from 2005 to 2009 were reviewed. A post-operative SSI occurred in 1,497 cases (4.6%). Using several statistical methods, the relationship between timing of prophylactic antibiotic administration and postoperative SSI within 30 days was evaluated.

In unadjusted models, higher SSI rates were observed with antibiotic administration more than 60 minutes prior to incision (OR 1.34, 95% CI 1.08-1.66) but not after incision (OR 1.26, 95% CI 0.92-1.72), compared with procedures with antibiotics administered within 60 minutes pre-incision. However, after adjustment for patient, procedure, and antibiotic variables, no significant relationship between timing and SSI was observed (P=0.50 for all specialties).

The study sample was comprised primarily of older men and did not include patients who underwent cardiac procedures, limiting the generalizability of the findings. Nonetheless, the study is the largest of its kind and confirms previous studies that suggest there is no significant relationship between timing of antibiotics and SSI. Prophylactic antibiotics should still be used when indicated; however, using timing of prophylactic antibiotics as a quality measure is unlikely to improve outcomes.

Bottom line: Adherence to the empiric 60-minute window metric for timing of prophylactic antibiotics is not significantly associated with risk of SSI.

Citation: Hawn MT, Richman JS, Vick CC, et al. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg. 2013 March 20:1-8. doi: 10.1001/jamasurg.2013.134 [Epub ahead of print].

Visit our website for more physician reviews of recent HM-relevant literature.

Clinical question: How does timing of surgical antibiotic prophylaxis affect risk of postoperative surgical-site infections (SSIs)?

Background: Antibiotic prophylaxis for major surgical procedures has been proven in clinical trials to reduce rates of SSI. The Centers for Medicare & Medicaid Services’ (CMS) Surgical Care Improvement Project (SCIP) has implemented quality metrics to ensure antibiotics are administered within 60 minutes of incision; however, studies have failed to show that a 60-minute pre-incision window is advantageous.

Study design: Retrospective cohort.

Setting: Veterans Affairs hospitals.

Synopsis: Using SCIP and VA Surgical Quality Improvement Program data from 112 VA hospitals, 32,459 cases of hip or knee arthroplasty, colorectal surgery, arterial vascular surgery, and hysterectomy from 2005 to 2009 were reviewed. A post-operative SSI occurred in 1,497 cases (4.6%). Using several statistical methods, the relationship between timing of prophylactic antibiotic administration and postoperative SSI within 30 days was evaluated.

In unadjusted models, higher SSI rates were observed with antibiotic administration more than 60 minutes prior to incision (OR 1.34, 95% CI 1.08-1.66) but not after incision (OR 1.26, 95% CI 0.92-1.72), compared with procedures with antibiotics administered within 60 minutes pre-incision. However, after adjustment for patient, procedure, and antibiotic variables, no significant relationship between timing and SSI was observed (P=0.50 for all specialties).

The study sample was comprised primarily of older men and did not include patients who underwent cardiac procedures, limiting the generalizability of the findings. Nonetheless, the study is the largest of its kind and confirms previous studies that suggest there is no significant relationship between timing of antibiotics and SSI. Prophylactic antibiotics should still be used when indicated; however, using timing of prophylactic antibiotics as a quality measure is unlikely to improve outcomes.

Bottom line: Adherence to the empiric 60-minute window metric for timing of prophylactic antibiotics is not significantly associated with risk of SSI.

Citation: Hawn MT, Richman JS, Vick CC, et al. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg. 2013 March 20:1-8. doi: 10.1001/jamasurg.2013.134 [Epub ahead of print].

Visit our website for more physician reviews of recent HM-relevant literature.

Clinical question: Is the use of proton-pump inhibitors (PPIs) associated with risk of mortality or combined risk of death or rehospitalization in older patients discharged from acute-care hospitals?

Background: Previous studies have shown that the use of PPIs could be associated with increased mortality in institutionalized older people and in patients discharged from acute-care hospitals. Older patients could be more vulnerable to adverse effects of PPIs, such as drug-drug interactions and absorption of nutrients, because of the higher incidence of polypharmacy and malnutrition in the elderly.

Study design: Prospective cohort.

Setting: Eleven acute-care medical wards participating in the Italian study Pharmacosurveillance in the Elderly Care.

Synopsis: All patients aged 65 years or older consecutively admitted to participating wards from April to June 2007 underwent screening. Excluding patients who refused, died during hospitalization, or were admitted to long-term care or rehabilitation units, a total of 491 patients were analyzed. The study team administered questionnaires during admission and conducted follow-up visits every three months for one year after discharge. Outcomes included one-year survival of patients discharged from acute-care medical wards and the combined endpoint of death or rehospitalization.

Overall, 174 patients (35.4%) had PPI exposure. After adjusting for age, cognitive impairment, disability, comorbidities, nutritional status, and number of drugs prescribed, patients exposed to PPIs had a significantly increased risk of death (adjusted HR 1.51, 95% CI 1.03-2.77). This association was strongest among patients receiving high-dose PPIs. No such association was found when considering the combined endpoint (HR 1.49, 95% CI 0.98-2.17). Limitations of the study include observational design, small size, potential for confounding by indication for PPI, and indeterminate PPI use prior to index hospitalization. Finally, the finding of an association between PPIs and increased mortality does not equate to a causative relationship between the two variables.

Bottom line: Proton-pump inhibitor use in older patients discharged from acute-care hospitals is associated with increased all-cause mortality at one year.

Citation: Maggio M, Corsonello A, Ceda GP, et al. Proton-pump inhibitors and risk of 1-year mortality and rehospitalization in older patients discharged from acute care hospitals. JAMA Intern Med. 2013;173(7):518-523.

Clinical question: Is the use of proton-pump inhibitors (PPIs) associated with risk of mortality or combined risk of death or rehospitalization in older patients discharged from acute-care hospitals?

Background: Previous studies have shown that the use of PPIs could be associated with increased mortality in institutionalized older people and in patients discharged from acute-care hospitals. Older patients could be more vulnerable to adverse effects of PPIs, such as drug-drug interactions and absorption of nutrients, because of the higher incidence of polypharmacy and malnutrition in the elderly.

Study design: Prospective cohort.

Setting: Eleven acute-care medical wards participating in the Italian study Pharmacosurveillance in the Elderly Care.

Synopsis: All patients aged 65 years or older consecutively admitted to participating wards from April to June 2007 underwent screening. Excluding patients who refused, died during hospitalization, or were admitted to long-term care or rehabilitation units, a total of 491 patients were analyzed. The study team administered questionnaires during admission and conducted follow-up visits every three months for one year after discharge. Outcomes included one-year survival of patients discharged from acute-care medical wards and the combined endpoint of death or rehospitalization.

Overall, 174 patients (35.4%) had PPI exposure. After adjusting for age, cognitive impairment, disability, comorbidities, nutritional status, and number of drugs prescribed, patients exposed to PPIs had a significantly increased risk of death (adjusted HR 1.51, 95% CI 1.03-2.77). This association was strongest among patients receiving high-dose PPIs. No such association was found when considering the combined endpoint (HR 1.49, 95% CI 0.98-2.17). Limitations of the study include observational design, small size, potential for confounding by indication for PPI, and indeterminate PPI use prior to index hospitalization. Finally, the finding of an association between PPIs and increased mortality does not equate to a causative relationship between the two variables.

Bottom line: Proton-pump inhibitor use in older patients discharged from acute-care hospitals is associated with increased all-cause mortality at one year.

Citation: Maggio M, Corsonello A, Ceda GP, et al. Proton-pump inhibitors and risk of 1-year mortality and rehospitalization in older patients discharged from acute care hospitals. JAMA Intern Med. 2013;173(7):518-523.

Clinical question: Is the use of proton-pump inhibitors (PPIs) associated with risk of mortality or combined risk of death or rehospitalization in older patients discharged from acute-care hospitals?

Background: Previous studies have shown that the use of PPIs could be associated with increased mortality in institutionalized older people and in patients discharged from acute-care hospitals. Older patients could be more vulnerable to adverse effects of PPIs, such as drug-drug interactions and absorption of nutrients, because of the higher incidence of polypharmacy and malnutrition in the elderly.

Study design: Prospective cohort.

Setting: Eleven acute-care medical wards participating in the Italian study Pharmacosurveillance in the Elderly Care.

Synopsis: All patients aged 65 years or older consecutively admitted to participating wards from April to June 2007 underwent screening. Excluding patients who refused, died during hospitalization, or were admitted to long-term care or rehabilitation units, a total of 491 patients were analyzed. The study team administered questionnaires during admission and conducted follow-up visits every three months for one year after discharge. Outcomes included one-year survival of patients discharged from acute-care medical wards and the combined endpoint of death or rehospitalization.

Overall, 174 patients (35.4%) had PPI exposure. After adjusting for age, cognitive impairment, disability, comorbidities, nutritional status, and number of drugs prescribed, patients exposed to PPIs had a significantly increased risk of death (adjusted HR 1.51, 95% CI 1.03-2.77). This association was strongest among patients receiving high-dose PPIs. No such association was found when considering the combined endpoint (HR 1.49, 95% CI 0.98-2.17). Limitations of the study include observational design, small size, potential for confounding by indication for PPI, and indeterminate PPI use prior to index hospitalization. Finally, the finding of an association between PPIs and increased mortality does not equate to a causative relationship between the two variables.

Bottom line: Proton-pump inhibitor use in older patients discharged from acute-care hospitals is associated with increased all-cause mortality at one year.

Citation: Maggio M, Corsonello A, Ceda GP, et al. Proton-pump inhibitors and risk of 1-year mortality and rehospitalization in older patients discharged from acute care hospitals. JAMA Intern Med. 2013;173(7):518-523.

Clinical question: Does uncontrolled diabetes mellitus increase risk for post-operative complications after elective joint replacement surgery?

Background: Several previous studies suggested that patients with uncontrolled diabetes could be at higher risk of postoperative complications and have worse functional outcomes after joint replacement surgery than patients without diabetes. Preoperative glycemic control is a potentially modifiable risk factor in patients undergoing elective joint replacement surgery. Demand for elective joint replacement is expected to increase over time, and reducing the risk of postoperative complications is essential in order to optimize functional outcomes and reduce healthcare costs.

Study design: Retrospective cohort.

Setting: Five regions of the Kaiser Permanente healthcare system.

Synopsis: The study included 40,491 patients aged 18 years and older who underwent primary knee replacement between January 2001 and December 2009 in five regions of the Kaiser Permanente system. Patients were identified using the Kaiser Permanente Total Joint Replacement Registry. Clinical information on each patient was collected from two years before the procedure to one year after the procedure using Kaiser Permanente electronic health records. Subjects were classified as nondiabetic (81.3%), diabetic with good glycemic control (12.5%), or diabetic with poor glycemic control (6.2%). Glycemic control status was assessed using the latest hemoglobin A1c (HbA1c) value measured prior to the date of the index surgery, with HbA1c <7.0% defined as good glycemic control. Outcomes included revision arthroplasty, deep infection, DVT or PE, incident myocardial infarction, and rehospitalization.

There was no significant association identified between uncontrolled diabetes and any of the five outcomes.

Limitations of the study include retrospective design, rarity of all outcomes except all-cause rehospitalization, and the small number of patients with uncontrolled diabetes in the cohort. In addition, functional outcomes were not assessed in this study.

Bottom line: The effect of uncontrolled diabetes on the risk of adverse surgical outcomes following elective joint replacement remains unclear based on currently published data; more studies are needed.

Citation: Adams AL, Paxton EW, Wang JQ, et al. Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001-2009. J Bone Joint Surg Am. 2013;95:481-487.

Clinical question: Does uncontrolled diabetes mellitus increase risk for post-operative complications after elective joint replacement surgery?

Background: Several previous studies suggested that patients with uncontrolled diabetes could be at higher risk of postoperative complications and have worse functional outcomes after joint replacement surgery than patients without diabetes. Preoperative glycemic control is a potentially modifiable risk factor in patients undergoing elective joint replacement surgery. Demand for elective joint replacement is expected to increase over time, and reducing the risk of postoperative complications is essential in order to optimize functional outcomes and reduce healthcare costs.

Study design: Retrospective cohort.

Setting: Five regions of the Kaiser Permanente healthcare system.

Synopsis: The study included 40,491 patients aged 18 years and older who underwent primary knee replacement between January 2001 and December 2009 in five regions of the Kaiser Permanente system. Patients were identified using the Kaiser Permanente Total Joint Replacement Registry. Clinical information on each patient was collected from two years before the procedure to one year after the procedure using Kaiser Permanente electronic health records. Subjects were classified as nondiabetic (81.3%), diabetic with good glycemic control (12.5%), or diabetic with poor glycemic control (6.2%). Glycemic control status was assessed using the latest hemoglobin A1c (HbA1c) value measured prior to the date of the index surgery, with HbA1c <7.0% defined as good glycemic control. Outcomes included revision arthroplasty, deep infection, DVT or PE, incident myocardial infarction, and rehospitalization.

There was no significant association identified between uncontrolled diabetes and any of the five outcomes.

Limitations of the study include retrospective design, rarity of all outcomes except all-cause rehospitalization, and the small number of patients with uncontrolled diabetes in the cohort. In addition, functional outcomes were not assessed in this study.

Bottom line: The effect of uncontrolled diabetes on the risk of adverse surgical outcomes following elective joint replacement remains unclear based on currently published data; more studies are needed.

Citation: Adams AL, Paxton EW, Wang JQ, et al. Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001-2009. J Bone Joint Surg Am. 2013;95:481-487.

Clinical question: Does uncontrolled diabetes mellitus increase risk for post-operative complications after elective joint replacement surgery?

Background: Several previous studies suggested that patients with uncontrolled diabetes could be at higher risk of postoperative complications and have worse functional outcomes after joint replacement surgery than patients without diabetes. Preoperative glycemic control is a potentially modifiable risk factor in patients undergoing elective joint replacement surgery. Demand for elective joint replacement is expected to increase over time, and reducing the risk of postoperative complications is essential in order to optimize functional outcomes and reduce healthcare costs.

Study design: Retrospective cohort.

Setting: Five regions of the Kaiser Permanente healthcare system.

Synopsis: The study included 40,491 patients aged 18 years and older who underwent primary knee replacement between January 2001 and December 2009 in five regions of the Kaiser Permanente system. Patients were identified using the Kaiser Permanente Total Joint Replacement Registry. Clinical information on each patient was collected from two years before the procedure to one year after the procedure using Kaiser Permanente electronic health records. Subjects were classified as nondiabetic (81.3%), diabetic with good glycemic control (12.5%), or diabetic with poor glycemic control (6.2%). Glycemic control status was assessed using the latest hemoglobin A1c (HbA1c) value measured prior to the date of the index surgery, with HbA1c <7.0% defined as good glycemic control. Outcomes included revision arthroplasty, deep infection, DVT or PE, incident myocardial infarction, and rehospitalization.

There was no significant association identified between uncontrolled diabetes and any of the five outcomes.

Limitations of the study include retrospective design, rarity of all outcomes except all-cause rehospitalization, and the small number of patients with uncontrolled diabetes in the cohort. In addition, functional outcomes were not assessed in this study.

Bottom line: The effect of uncontrolled diabetes on the risk of adverse surgical outcomes following elective joint replacement remains unclear based on currently published data; more studies are needed.

Citation: Adams AL, Paxton EW, Wang JQ, et al. Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001-2009. J Bone Joint Surg Am. 2013;95:481-487.

Clinical question: What are the effects of the 2011 resident duty-hour requirements on first-year residents’ well-being and patient safety?

Background: In an effort to reduce adverse consequences associated with extended shift length and sleep deprivation, the Accreditation Council for Graduate Medical Education (ACGME) released a new set of duty-hour requirements effective July 2011. To date, little is known about the effects of the 2011 reforms on resident and patient outcomes.

Study design: Prospective, longitudinal cohort with pre-post analysis.

Setting: Residency programs from university- and community-based medical centers.

Synopsis: Fifty-one residency programs from 10 university-based and four community-based GME institutions were included. Incoming interns during the 2009, 2010, and 2011 academic years were invited to participate, and 58% (n=2,323) agreed to take part. Participants completed online surveys two months before starting their first residency (intern) year and at three, six, nine, and 12 months of internship. Questions addressed work hours, sleep, medical errors, depressive symptoms, and subjective well-being.

No significant differences in baseline findings were found between the pre-implementation cohort (interns entering in 2009 and 2010) and the post-implementation cohort (interns starting in 2011, following the new duty-hour requirements). Interns in the post-implementation cohort worked fewer hours than those in the pre-implementation cohort (mean hours per week 64.3 vs. 67.0, P<0.001). There were no significant changes in reported hours of sleep, depressive symptom score, or well-being score between the pre- and post-implementation cohorts. The percentage of respondents who reported committing a serious medical error increased in the post-implementation group (23.3% vs. 19.9%, P=0.007).

Limitations include the self-reported nature of the responses and the modest participation rate. The authors concluded that although the 2011 reforms decreased the total number of hours worked, additional strategies could be needed to achieve the desired effects on intern well-being and patient safety.

Bottom line: Following implementation of the 2011 ACGME duty-hour reforms, interns from diverse specialties and institutions experienced reductions in self-reported work hours, without any associated improvements in sleep, depressive symptoms, or well-being and with an increase in reported medical errors.

Citation: Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. JAMA Intern Med. 2013;173(8):657-662.

Clinical question: What are the effects of the 2011 resident duty-hour requirements on first-year residents’ well-being and patient safety?

Background: In an effort to reduce adverse consequences associated with extended shift length and sleep deprivation, the Accreditation Council for Graduate Medical Education (ACGME) released a new set of duty-hour requirements effective July 2011. To date, little is known about the effects of the 2011 reforms on resident and patient outcomes.

Study design: Prospective, longitudinal cohort with pre-post analysis.

Setting: Residency programs from university- and community-based medical centers.

Synopsis: Fifty-one residency programs from 10 university-based and four community-based GME institutions were included. Incoming interns during the 2009, 2010, and 2011 academic years were invited to participate, and 58% (n=2,323) agreed to take part. Participants completed online surveys two months before starting their first residency (intern) year and at three, six, nine, and 12 months of internship. Questions addressed work hours, sleep, medical errors, depressive symptoms, and subjective well-being.

No significant differences in baseline findings were found between the pre-implementation cohort (interns entering in 2009 and 2010) and the post-implementation cohort (interns starting in 2011, following the new duty-hour requirements). Interns in the post-implementation cohort worked fewer hours than those in the pre-implementation cohort (mean hours per week 64.3 vs. 67.0, P<0.001). There were no significant changes in reported hours of sleep, depressive symptom score, or well-being score between the pre- and post-implementation cohorts. The percentage of respondents who reported committing a serious medical error increased in the post-implementation group (23.3% vs. 19.9%, P=0.007).

Limitations include the self-reported nature of the responses and the modest participation rate. The authors concluded that although the 2011 reforms decreased the total number of hours worked, additional strategies could be needed to achieve the desired effects on intern well-being and patient safety.

Bottom line: Following implementation of the 2011 ACGME duty-hour reforms, interns from diverse specialties and institutions experienced reductions in self-reported work hours, without any associated improvements in sleep, depressive symptoms, or well-being and with an increase in reported medical errors.

Citation: Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. JAMA Intern Med. 2013;173(8):657-662.

Clinical question: What are the effects of the 2011 resident duty-hour requirements on first-year residents’ well-being and patient safety?

Background: In an effort to reduce adverse consequences associated with extended shift length and sleep deprivation, the Accreditation Council for Graduate Medical Education (ACGME) released a new set of duty-hour requirements effective July 2011. To date, little is known about the effects of the 2011 reforms on resident and patient outcomes.

Study design: Prospective, longitudinal cohort with pre-post analysis.

Setting: Residency programs from university- and community-based medical centers.

Synopsis: Fifty-one residency programs from 10 university-based and four community-based GME institutions were included. Incoming interns during the 2009, 2010, and 2011 academic years were invited to participate, and 58% (n=2,323) agreed to take part. Participants completed online surveys two months before starting their first residency (intern) year and at three, six, nine, and 12 months of internship. Questions addressed work hours, sleep, medical errors, depressive symptoms, and subjective well-being.

No significant differences in baseline findings were found between the pre-implementation cohort (interns entering in 2009 and 2010) and the post-implementation cohort (interns starting in 2011, following the new duty-hour requirements). Interns in the post-implementation cohort worked fewer hours than those in the pre-implementation cohort (mean hours per week 64.3 vs. 67.0, P<0.001). There were no significant changes in reported hours of sleep, depressive symptom score, or well-being score between the pre- and post-implementation cohorts. The percentage of respondents who reported committing a serious medical error increased in the post-implementation group (23.3% vs. 19.9%, P=0.007).

Limitations include the self-reported nature of the responses and the modest participation rate. The authors concluded that although the 2011 reforms decreased the total number of hours worked, additional strategies could be needed to achieve the desired effects on intern well-being and patient safety.

Bottom line: Following implementation of the 2011 ACGME duty-hour reforms, interns from diverse specialties and institutions experienced reductions in self-reported work hours, without any associated improvements in sleep, depressive symptoms, or well-being and with an increase in reported medical errors.

Citation: Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. JAMA Intern Med. 2013;173(8):657-662.

Clinical question: Are high plasma lactate levels associated with mortality and clinical deterioration among patients with acute pulmonary embolism (PE)?

Background: Prognostic clinical markers are limited in patients presenting with acute PE, especially among normotensive individuals. Plasma lactate concentration is a marker of tissue hypoperfusion that has been used to risk-stratify patients with sepsis and trauma. It is unknown whether elevated lactate levels predict poor outcomes in acute PE.

Study design: Prospective cohort.

Setting: ED in a large teaching hospital in Italy.

Synopsis: Consecutive adult patients with acute PE diagnosed by spiral computed tomography or lung scan were included. Plasma lactate levels were tested in all patients at presentation, and levels of ≥2 mmol/L were considered abnormal. The primary endpoint was all-cause death within 30 days, and the secondary endpoint was the composite of all-cause death and PE-related clinical deterioration and death.

Of the 270 patients, 81 (30%) had abnormal lactate levels, though only 12 (4.4%) had shock or hypotension. Patients with elevated lactate had higher mortality compared with patients with lower levels (17.3% vs. 1.6%, OR 12.95, 95% CI 3.43-58.73). Plasma lactate ≥2 mmol/L was associated with higher all-cause mortality (HR 11.67, 95% CI 3.32-41.03) and the composite endpoint (HR 8.14, 95% CI 3.83-17.34). This association was independent of the presence of hypotension, right ventricular dysfunction, or elevated troponin.

Limitations include the single study site (which limits generalizability of the findings) and that lactate levels were only checked once (which might not have fully reflected each patient’s clinical picture). The authors suggest that plasma lactate levels might have utility in determining which patients should be treated more aggressively for PE.

Bottom line: In patients presenting with acute PE, elevated plasma lactate levels are associated with increased risk of short-term mortality and morbidity, independent of the presence of hypotension or markers of right ventricular injury.

Citation: Vanni S, Viviani G, Baioni M, et al. Prognostic value of plasma lactate levels among patients with acute pulmonary embolism: the thrombo-embolism lactate outcome study. Ann Emerg Med. 2013;61:330-338.

Clinical question: Are high plasma lactate levels associated with mortality and clinical deterioration among patients with acute pulmonary embolism (PE)?

Background: Prognostic clinical markers are limited in patients presenting with acute PE, especially among normotensive individuals. Plasma lactate concentration is a marker of tissue hypoperfusion that has been used to risk-stratify patients with sepsis and trauma. It is unknown whether elevated lactate levels predict poor outcomes in acute PE.

Study design: Prospective cohort.

Setting: ED in a large teaching hospital in Italy.

Synopsis: Consecutive adult patients with acute PE diagnosed by spiral computed tomography or lung scan were included. Plasma lactate levels were tested in all patients at presentation, and levels of ≥2 mmol/L were considered abnormal. The primary endpoint was all-cause death within 30 days, and the secondary endpoint was the composite of all-cause death and PE-related clinical deterioration and death.

Of the 270 patients, 81 (30%) had abnormal lactate levels, though only 12 (4.4%) had shock or hypotension. Patients with elevated lactate had higher mortality compared with patients with lower levels (17.3% vs. 1.6%, OR 12.95, 95% CI 3.43-58.73). Plasma lactate ≥2 mmol/L was associated with higher all-cause mortality (HR 11.67, 95% CI 3.32-41.03) and the composite endpoint (HR 8.14, 95% CI 3.83-17.34). This association was independent of the presence of hypotension, right ventricular dysfunction, or elevated troponin.

Limitations include the single study site (which limits generalizability of the findings) and that lactate levels were only checked once (which might not have fully reflected each patient’s clinical picture). The authors suggest that plasma lactate levels might have utility in determining which patients should be treated more aggressively for PE.

Bottom line: In patients presenting with acute PE, elevated plasma lactate levels are associated with increased risk of short-term mortality and morbidity, independent of the presence of hypotension or markers of right ventricular injury.

Citation: Vanni S, Viviani G, Baioni M, et al. Prognostic value of plasma lactate levels among patients with acute pulmonary embolism: the thrombo-embolism lactate outcome study. Ann Emerg Med. 2013;61:330-338.

Clinical question: Are high plasma lactate levels associated with mortality and clinical deterioration among patients with acute pulmonary embolism (PE)?

Background: Prognostic clinical markers are limited in patients presenting with acute PE, especially among normotensive individuals. Plasma lactate concentration is a marker of tissue hypoperfusion that has been used to risk-stratify patients with sepsis and trauma. It is unknown whether elevated lactate levels predict poor outcomes in acute PE.

Study design: Prospective cohort.

Setting: ED in a large teaching hospital in Italy.

Synopsis: Consecutive adult patients with acute PE diagnosed by spiral computed tomography or lung scan were included. Plasma lactate levels were tested in all patients at presentation, and levels of ≥2 mmol/L were considered abnormal. The primary endpoint was all-cause death within 30 days, and the secondary endpoint was the composite of all-cause death and PE-related clinical deterioration and death.

Of the 270 patients, 81 (30%) had abnormal lactate levels, though only 12 (4.4%) had shock or hypotension. Patients with elevated lactate had higher mortality compared with patients with lower levels (17.3% vs. 1.6%, OR 12.95, 95% CI 3.43-58.73). Plasma lactate ≥2 mmol/L was associated with higher all-cause mortality (HR 11.67, 95% CI 3.32-41.03) and the composite endpoint (HR 8.14, 95% CI 3.83-17.34). This association was independent of the presence of hypotension, right ventricular dysfunction, or elevated troponin.

Limitations include the single study site (which limits generalizability of the findings) and that lactate levels were only checked once (which might not have fully reflected each patient’s clinical picture). The authors suggest that plasma lactate levels might have utility in determining which patients should be treated more aggressively for PE.

Bottom line: In patients presenting with acute PE, elevated plasma lactate levels are associated with increased risk of short-term mortality and morbidity, independent of the presence of hypotension or markers of right ventricular injury.

Citation: Vanni S, Viviani G, Baioni M, et al. Prognostic value of plasma lactate levels among patients with acute pulmonary embolism: the thrombo-embolism lactate outcome study. Ann Emerg Med. 2013;61:330-338.

Clinical question: How often do inpatient providers report direct communication with outpatient providers, and how is direct communication associated with 30-day readmissions?

Background: Studies have demonstrated that adverse events and errors occurring after hospital discharge can result from poor provider communication between the inpatient and outpatient setting.

Study design: Prospective cohort.

Setting: Johns Hopkins Hospital, Baltimore.

Synopsis: The presence or absence of direct communication between inpatient and outpatient healthcare providers was captured from a required field in an electronic discharge worksheet completed by the discharging physician. Of 6,635 hospitalizations studied, successful direct communication was reported in 36.7% of cases. Predictors of successful direct communication included patients cared for by hospitalists without house staff (OR 1.81, 95% CI 1.59-2.08), high expected 30-day readmission rate (OR 1.18, 95% CI 1.10-1.28), and insurance by Medicare (OR 1.35, 95% CI 1.16-1.56) and private insurance companies (OR 1.35, 95% CI 1.18-1.56). In adjusted analyses, direct communication between the inpatient and outpatient providers was not associated with 30-day readmissions (OR 1.08, 95% CI 0.92-1.26).

There were several limitations in this study. Only the primary team was surveyed; thus, it is not known if consulting providers might have contacted the outpatient providers. Only readmissions to the same medical center were studied, and therefore it is not known if patients were readmitted to other facilities. Additionally, information regarding discharge communication was self-reported, which might have introduced bias.

Bottom line: Self-reported direct communication between inpatient and outpatient providers occurred infrequently and was not associated with 30-day same-hospital readmission.

Citation: Oduyebo I, Lehmann C, Pollack C, et al. Association of self-reported hospital discharge handoffs with 30-day readmissions. JAMA Intern Med. 2013;173:624-629.

Clinical question: How often do inpatient providers report direct communication with outpatient providers, and how is direct communication associated with 30-day readmissions?

Background: Studies have demonstrated that adverse events and errors occurring after hospital discharge can result from poor provider communication between the inpatient and outpatient setting.

Study design: Prospective cohort.

Setting: Johns Hopkins Hospital, Baltimore.

Synopsis: The presence or absence of direct communication between inpatient and outpatient healthcare providers was captured from a required field in an electronic discharge worksheet completed by the discharging physician. Of 6,635 hospitalizations studied, successful direct communication was reported in 36.7% of cases. Predictors of successful direct communication included patients cared for by hospitalists without house staff (OR 1.81, 95% CI 1.59-2.08), high expected 30-day readmission rate (OR 1.18, 95% CI 1.10-1.28), and insurance by Medicare (OR 1.35, 95% CI 1.16-1.56) and private insurance companies (OR 1.35, 95% CI 1.18-1.56). In adjusted analyses, direct communication between the inpatient and outpatient providers was not associated with 30-day readmissions (OR 1.08, 95% CI 0.92-1.26).

There were several limitations in this study. Only the primary team was surveyed; thus, it is not known if consulting providers might have contacted the outpatient providers. Only readmissions to the same medical center were studied, and therefore it is not known if patients were readmitted to other facilities. Additionally, information regarding discharge communication was self-reported, which might have introduced bias.

Bottom line: Self-reported direct communication between inpatient and outpatient providers occurred infrequently and was not associated with 30-day same-hospital readmission.

Citation: Oduyebo I, Lehmann C, Pollack C, et al. Association of self-reported hospital discharge handoffs with 30-day readmissions. JAMA Intern Med. 2013;173:624-629.

Clinical question: How often do inpatient providers report direct communication with outpatient providers, and how is direct communication associated with 30-day readmissions?

Background: Studies have demonstrated that adverse events and errors occurring after hospital discharge can result from poor provider communication between the inpatient and outpatient setting.

Study design: Prospective cohort.

Setting: Johns Hopkins Hospital, Baltimore.

Synopsis: The presence or absence of direct communication between inpatient and outpatient healthcare providers was captured from a required field in an electronic discharge worksheet completed by the discharging physician. Of 6,635 hospitalizations studied, successful direct communication was reported in 36.7% of cases. Predictors of successful direct communication included patients cared for by hospitalists without house staff (OR 1.81, 95% CI 1.59-2.08), high expected 30-day readmission rate (OR 1.18, 95% CI 1.10-1.28), and insurance by Medicare (OR 1.35, 95% CI 1.16-1.56) and private insurance companies (OR 1.35, 95% CI 1.18-1.56). In adjusted analyses, direct communication between the inpatient and outpatient providers was not associated with 30-day readmissions (OR 1.08, 95% CI 0.92-1.26).

There were several limitations in this study. Only the primary team was surveyed; thus, it is not known if consulting providers might have contacted the outpatient providers. Only readmissions to the same medical center were studied, and therefore it is not known if patients were readmitted to other facilities. Additionally, information regarding discharge communication was self-reported, which might have introduced bias.

Bottom line: Self-reported direct communication between inpatient and outpatient providers occurred infrequently and was not associated with 30-day same-hospital readmission.

Citation: Oduyebo I, Lehmann C, Pollack C, et al. Association of self-reported hospital discharge handoffs with 30-day readmissions. JAMA Intern Med. 2013;173:624-629.

Clinical question: In patients who undergo inferior vena cava (IVC) filter placement for venous thromboembolism (VTE) prophylaxis or treatment, what are the associated patient characteristics, indications for placement, complications, retrieval date, and use of concomitant anticoagulant therapy?

Background: Retrievable IVC filters were designed to provide short-term protection from pulmonary embolism but are often left in place indefinitely. Retrievable IVC filters that are not removed can carry significant long-term risks. Further, the use of filters for VTE prophylaxis is controversial, and there are multiple sets of conflicting guidelines for filter insertion provided by various professional groups.

Study design: Retrospective review of IVC filter use over an eight-year period.

Setting: Boston Medical Center.

Synopsis: Medical records from all patients at Boston Medical Center who had a billing code for placement of an IVC filter between August 2003 and February 2011 were manually reviewed. Nine hundred fifty-two medical records were evaluated, of which 679 (71.3%) patients had retrievable IVC filters placed. The most common indications for filter placement were trauma (50.2%), malignancy (15.9%), and bleeding during anticoagulation (11.8%).

In total, 448 patients (47.1%) had filters placed for prophylactic purposes in the absence of documented VTE. Seventy-four patients developed VTE after filter placement; 48.2% of post-filter insertion VTEs occurred in patients who had no VTE prior to the filter; and 89.4% occurred in patients not receiving anticoagulants. An attempt was made to remove 71 of 679 (10.5%) retrievable filters, and 58 (8.5%) attempts were successful. There were 10 serious complications related to mechanical filter failure, including migration or fracture of the filter.

In this study, there was a high volume of filter use by the trauma service; thus, the patient population might be different from the hospital medicine patient population. The study also lacked systematic imaging and follow-up data. Further studies are needed to analyze the risks associated with IVC filter placement.

Bottom line: Use of IVC filters for VTE treatment and prophylaxis, in the context of low filter retrieval rates and lack of appropriate anticoagulant therapy, results in suboptimal outcomes.

Citation: Sarosiek S, Crowther M, Sloan M. Indications, complications, and management of inferior vena cava filters: the experience in 952 patients at an academic hospital with a level I trauma center. JAMA Intern Med. 2013;173:513-517.

Clinical question: In patients who undergo inferior vena cava (IVC) filter placement for venous thromboembolism (VTE) prophylaxis or treatment, what are the associated patient characteristics, indications for placement, complications, retrieval date, and use of concomitant anticoagulant therapy?

Background: Retrievable IVC filters were designed to provide short-term protection from pulmonary embolism but are often left in place indefinitely. Retrievable IVC filters that are not removed can carry significant long-term risks. Further, the use of filters for VTE prophylaxis is controversial, and there are multiple sets of conflicting guidelines for filter insertion provided by various professional groups.

Study design: Retrospective review of IVC filter use over an eight-year period.

Setting: Boston Medical Center.

Synopsis: Medical records from all patients at Boston Medical Center who had a billing code for placement of an IVC filter between August 2003 and February 2011 were manually reviewed. Nine hundred fifty-two medical records were evaluated, of which 679 (71.3%) patients had retrievable IVC filters placed. The most common indications for filter placement were trauma (50.2%), malignancy (15.9%), and bleeding during anticoagulation (11.8%).

In total, 448 patients (47.1%) had filters placed for prophylactic purposes in the absence of documented VTE. Seventy-four patients developed VTE after filter placement; 48.2% of post-filter insertion VTEs occurred in patients who had no VTE prior to the filter; and 89.4% occurred in patients not receiving anticoagulants. An attempt was made to remove 71 of 679 (10.5%) retrievable filters, and 58 (8.5%) attempts were successful. There were 10 serious complications related to mechanical filter failure, including migration or fracture of the filter.

In this study, there was a high volume of filter use by the trauma service; thus, the patient population might be different from the hospital medicine patient population. The study also lacked systematic imaging and follow-up data. Further studies are needed to analyze the risks associated with IVC filter placement.

Bottom line: Use of IVC filters for VTE treatment and prophylaxis, in the context of low filter retrieval rates and lack of appropriate anticoagulant therapy, results in suboptimal outcomes.

Citation: Sarosiek S, Crowther M, Sloan M. Indications, complications, and management of inferior vena cava filters: the experience in 952 patients at an academic hospital with a level I trauma center. JAMA Intern Med. 2013;173:513-517.

Clinical question: In patients who undergo inferior vena cava (IVC) filter placement for venous thromboembolism (VTE) prophylaxis or treatment, what are the associated patient characteristics, indications for placement, complications, retrieval date, and use of concomitant anticoagulant therapy?

Background: Retrievable IVC filters were designed to provide short-term protection from pulmonary embolism but are often left in place indefinitely. Retrievable IVC filters that are not removed can carry significant long-term risks. Further, the use of filters for VTE prophylaxis is controversial, and there are multiple sets of conflicting guidelines for filter insertion provided by various professional groups.

Study design: Retrospective review of IVC filter use over an eight-year period.

Setting: Boston Medical Center.

Synopsis: Medical records from all patients at Boston Medical Center who had a billing code for placement of an IVC filter between August 2003 and February 2011 were manually reviewed. Nine hundred fifty-two medical records were evaluated, of which 679 (71.3%) patients had retrievable IVC filters placed. The most common indications for filter placement were trauma (50.2%), malignancy (15.9%), and bleeding during anticoagulation (11.8%).

In total, 448 patients (47.1%) had filters placed for prophylactic purposes in the absence of documented VTE. Seventy-four patients developed VTE after filter placement; 48.2% of post-filter insertion VTEs occurred in patients who had no VTE prior to the filter; and 89.4% occurred in patients not receiving anticoagulants. An attempt was made to remove 71 of 679 (10.5%) retrievable filters, and 58 (8.5%) attempts were successful. There were 10 serious complications related to mechanical filter failure, including migration or fracture of the filter.

In this study, there was a high volume of filter use by the trauma service; thus, the patient population might be different from the hospital medicine patient population. The study also lacked systematic imaging and follow-up data. Further studies are needed to analyze the risks associated with IVC filter placement.

Bottom line: Use of IVC filters for VTE treatment and prophylaxis, in the context of low filter retrieval rates and lack of appropriate anticoagulant therapy, results in suboptimal outcomes.

Citation: Sarosiek S, Crowther M, Sloan M. Indications, complications, and management of inferior vena cava filters: the experience in 952 patients at an academic hospital with a level I trauma center. JAMA Intern Med. 2013;173:513-517.

Clinical question: Can a prediction model based on administrative and clinical data identify potentially avoidable 30-day readmissions in medical patients prior to discharge?

Background: An estimated 18% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge, costing nearly $17 billion per year. Interventions to reduce readmission rates are costly and should be focused on high-risk patients. To date, using models to predict 30-day readmission has been problematic and unreliable.

Study design: Retrospective cohort.

Setting: Academic medical center in Boston.

Synopsis: Using consecutive discharges from all medical services of Brigham and Women’s Hospital occurring over one year, this study derived and internally validated a prediction model for potentially avoidable 30-day readmissions. Of 10,731 discharges, there were 2,399 (22%) 30-day readmissions, and 879 (8.5%) were deemed potentially avoidable. Seven independent predictors for readmission were identified and used to create a predictor score referred to as the HOSPITAL score. Predictors included hemoglobin and sodium levels at discharge, number of hospitalizations in the past year, and four features of the index hospitalization, including type, discharge from an oncology service, presence of procedures, and length of stay. The score was internally validated and found to predict potentially avoidable 30-day readmission in medical patients with fair discriminatory power and good calibration.

This study is unique in that none of the classic comorbidities (e.g. congestive heart failure) were associated with a higher risk of 30-day readmission. Previously unrecognized predictors, including hemoglobin, sodium, and number of procedures performed, were incorporated. This suggests that comorbidities are not as important as illness severity or clinical instability. Hospitalists should await studies that externally validate the HOSPITAL score before incorporating it into practice.

Bottom line: A unique and simple seven-item prediction model identifies potentially avoidable 30-day readmissions but needs to be externally validated before being widely utilized.

Citation: Donze J, Drahomir A, Williams D, Schnipper JL. Potentially avoidable 30-day hospital readmissions in medical patients. JAMA Intern Med. 2013;137(8):632-638.

Clinical question: Can a prediction model based on administrative and clinical data identify potentially avoidable 30-day readmissions in medical patients prior to discharge?

Background: An estimated 18% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge, costing nearly $17 billion per year. Interventions to reduce readmission rates are costly and should be focused on high-risk patients. To date, using models to predict 30-day readmission has been problematic and unreliable.

Study design: Retrospective cohort.

Setting: Academic medical center in Boston.

Synopsis: Using consecutive discharges from all medical services of Brigham and Women’s Hospital occurring over one year, this study derived and internally validated a prediction model for potentially avoidable 30-day readmissions. Of 10,731 discharges, there were 2,399 (22%) 30-day readmissions, and 879 (8.5%) were deemed potentially avoidable. Seven independent predictors for readmission were identified and used to create a predictor score referred to as the HOSPITAL score. Predictors included hemoglobin and sodium levels at discharge, number of hospitalizations in the past year, and four features of the index hospitalization, including type, discharge from an oncology service, presence of procedures, and length of stay. The score was internally validated and found to predict potentially avoidable 30-day readmission in medical patients with fair discriminatory power and good calibration.

This study is unique in that none of the classic comorbidities (e.g. congestive heart failure) were associated with a higher risk of 30-day readmission. Previously unrecognized predictors, including hemoglobin, sodium, and number of procedures performed, were incorporated. This suggests that comorbidities are not as important as illness severity or clinical instability. Hospitalists should await studies that externally validate the HOSPITAL score before incorporating it into practice.

Bottom line: A unique and simple seven-item prediction model identifies potentially avoidable 30-day readmissions but needs to be externally validated before being widely utilized.

Citation: Donze J, Drahomir A, Williams D, Schnipper JL. Potentially avoidable 30-day hospital readmissions in medical patients. JAMA Intern Med. 2013;137(8):632-638.

Clinical question: Can a prediction model based on administrative and clinical data identify potentially avoidable 30-day readmissions in medical patients prior to discharge?

Background: An estimated 18% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge, costing nearly $17 billion per year. Interventions to reduce readmission rates are costly and should be focused on high-risk patients. To date, using models to predict 30-day readmission has been problematic and unreliable.

Study design: Retrospective cohort.

Setting: Academic medical center in Boston.

Synopsis: Using consecutive discharges from all medical services of Brigham and Women’s Hospital occurring over one year, this study derived and internally validated a prediction model for potentially avoidable 30-day readmissions. Of 10,731 discharges, there were 2,399 (22%) 30-day readmissions, and 879 (8.5%) were deemed potentially avoidable. Seven independent predictors for readmission were identified and used to create a predictor score referred to as the HOSPITAL score. Predictors included hemoglobin and sodium levels at discharge, number of hospitalizations in the past year, and four features of the index hospitalization, including type, discharge from an oncology service, presence of procedures, and length of stay. The score was internally validated and found to predict potentially avoidable 30-day readmission in medical patients with fair discriminatory power and good calibration.

This study is unique in that none of the classic comorbidities (e.g. congestive heart failure) were associated with a higher risk of 30-day readmission. Previously unrecognized predictors, including hemoglobin, sodium, and number of procedures performed, were incorporated. This suggests that comorbidities are not as important as illness severity or clinical instability. Hospitalists should await studies that externally validate the HOSPITAL score before incorporating it into practice.

Bottom line: A unique and simple seven-item prediction model identifies potentially avoidable 30-day readmissions but needs to be externally validated before being widely utilized.

Citation: Donze J, Drahomir A, Williams D, Schnipper JL. Potentially avoidable 30-day hospital readmissions in medical patients. JAMA Intern Med. 2013;137(8):632-638.

Clinical question: How does timing of surgical antibiotic prophylaxis affect risk of postoperative surgical-site infections (SSIs)?

Background: Antibiotic prophylaxis for major surgical procedures has been proven in clinical trials to reduce rates of SSI. The Centers for Medicare & Medicaid Services’ (CMS) Surgical Care Improvement Project (SCIP) has implemented quality metrics to ensure antibiotics are administered within 60 minutes of incision; however, studies have failed to show that a 60-minute pre-incision window is advantageous.

Study design: Retrospective cohort.

Setting: Veterans Affairs hospitals.

Synopsis: Using SCIP and VA Surgical Quality Improvement Program data from 112 VA hospitals, 32,459 cases of hip or knee arthroplasty, colorectal surgery, arterial vascular surgery, and hysterectomy from 2005-2009 were reviewed. A postoperative SSI occurred in 1,497 cases (4.6%). Using several statistical methods, the relationship between timing of prophylactic antibiotic administration and postoperative SSI within 30 days was evaluated. In unadjusted models, higher SSI rates were observed with antibiotic administration more than 60 minutes prior to incision (OR 1.34, 95% CI 1.08-1.66) but not after incision (OR 1.26, 95% CI 0.92-1.72), compared with procedures with antibiotics administered within 60 minutes pre-incision. However, after adjustment for patient, procedure, and antibiotic variables, no significant relationship between timing and SSI was observed (P=0.50 for all specialties).

The study sample was comprised primarily of older men and did not include patients who underwent cardiac procedures, limiting the generalizability of the findings. Nonetheless, the study is the largest of its kind and confirms previous studies that suggest there is no significant relationship between timing of antibiotics and SSI. Prophylactic antibiotics should still be used when indicated; however, using timing of prophylactic antibiotics as a quality measure is unlikely to improve outcomes.

Bottom line: Adherence to the empiric 60-minute window metric for timing of prophylactic antibiotics is not significantly associated with risk of SSI.

Citation: Hawn MT, Richman JS, Vick CC, et al. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg. 2013 March 20:1-8. doi: 10.1001/jamasurg.2013.134 [Epub ahead of print].

Clinical question: How does timing of surgical antibiotic prophylaxis affect risk of postoperative surgical-site infections (SSIs)?

Background: Antibiotic prophylaxis for major surgical procedures has been proven in clinical trials to reduce rates of SSI. The Centers for Medicare & Medicaid Services’ (CMS) Surgical Care Improvement Project (SCIP) has implemented quality metrics to ensure antibiotics are administered within 60 minutes of incision; however, studies have failed to show that a 60-minute pre-incision window is advantageous.

Study design: Retrospective cohort.

Setting: Veterans Affairs hospitals.

Synopsis: Using SCIP and VA Surgical Quality Improvement Program data from 112 VA hospitals, 32,459 cases of hip or knee arthroplasty, colorectal surgery, arterial vascular surgery, and hysterectomy from 2005-2009 were reviewed. A postoperative SSI occurred in 1,497 cases (4.6%). Using several statistical methods, the relationship between timing of prophylactic antibiotic administration and postoperative SSI within 30 days was evaluated. In unadjusted models, higher SSI rates were observed with antibiotic administration more than 60 minutes prior to incision (OR 1.34, 95% CI 1.08-1.66) but not after incision (OR 1.26, 95% CI 0.92-1.72), compared with procedures with antibiotics administered within 60 minutes pre-incision. However, after adjustment for patient, procedure, and antibiotic variables, no significant relationship between timing and SSI was observed (P=0.50 for all specialties).

The study sample was comprised primarily of older men and did not include patients who underwent cardiac procedures, limiting the generalizability of the findings. Nonetheless, the study is the largest of its kind and confirms previous studies that suggest there is no significant relationship between timing of antibiotics and SSI. Prophylactic antibiotics should still be used when indicated; however, using timing of prophylactic antibiotics as a quality measure is unlikely to improve outcomes.

Bottom line: Adherence to the empiric 60-minute window metric for timing of prophylactic antibiotics is not significantly associated with risk of SSI.

Citation: Hawn MT, Richman JS, Vick CC, et al. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg. 2013 March 20:1-8. doi: 10.1001/jamasurg.2013.134 [Epub ahead of print].

Clinical question: How does timing of surgical antibiotic prophylaxis affect risk of postoperative surgical-site infections (SSIs)?

Background: Antibiotic prophylaxis for major surgical procedures has been proven in clinical trials to reduce rates of SSI. The Centers for Medicare & Medicaid Services’ (CMS) Surgical Care Improvement Project (SCIP) has implemented quality metrics to ensure antibiotics are administered within 60 minutes of incision; however, studies have failed to show that a 60-minute pre-incision window is advantageous.

Study design: Retrospective cohort.

Setting: Veterans Affairs hospitals.

Synopsis: Using SCIP and VA Surgical Quality Improvement Program data from 112 VA hospitals, 32,459 cases of hip or knee arthroplasty, colorectal surgery, arterial vascular surgery, and hysterectomy from 2005-2009 were reviewed. A postoperative SSI occurred in 1,497 cases (4.6%). Using several statistical methods, the relationship between timing of prophylactic antibiotic administration and postoperative SSI within 30 days was evaluated. In unadjusted models, higher SSI rates were observed with antibiotic administration more than 60 minutes prior to incision (OR 1.34, 95% CI 1.08-1.66) but not after incision (OR 1.26, 95% CI 0.92-1.72), compared with procedures with antibiotics administered within 60 minutes pre-incision. However, after adjustment for patient, procedure, and antibiotic variables, no significant relationship between timing and SSI was observed (P=0.50 for all specialties).

The study sample was comprised primarily of older men and did not include patients who underwent cardiac procedures, limiting the generalizability of the findings. Nonetheless, the study is the largest of its kind and confirms previous studies that suggest there is no significant relationship between timing of antibiotics and SSI. Prophylactic antibiotics should still be used when indicated; however, using timing of prophylactic antibiotics as a quality measure is unlikely to improve outcomes.

Bottom line: Adherence to the empiric 60-minute window metric for timing of prophylactic antibiotics is not significantly associated with risk of SSI.

Citation: Hawn MT, Richman JS, Vick CC, et al. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg. 2013 March 20:1-8. doi: 10.1001/jamasurg.2013.134 [Epub ahead of print].

Clinical question: What is the long-term outcome of elderly survivors of in-hospital cardiac arrest?

Background: Previous studies have examined in-hospital survival from in-hospital cardiac arrest but have not looked at long-term outcomes and readmission of in-hospital cardiac arrest survivors.

Study design: Retrospective cohort.

Setting: Acute-care hospitals that submitted data to the Get with the Guidelines—Resuscitation registry between 2000 and 2008.

Synopsis: Using the Get with the Guidelines—Resuscitation registry from 401 acute-care hospitals, data from 6,972 Medicare patients aged 65 years or older who had a pulseless in-hospital cardiac arrest and survived to discharge were analyzed. Survival rates were 82% at 30 days, 72% at three months, 58.5% at one year, and 49.6% at two years. Survival at three years was 43.5%, similar to patients discharged with heart failure.

One-year survival decreased with increasing age. Survival also decreased with black race (52.5% vs. 60.4% for white patients, P=0.001) and male sex (58.6% vs. 60.9% for women, P=0.03). Patients with mild or no neurologic disability at discharge had a higher survival rate at one year than patients with moderate, severe, or coma state. Readmission rates at one year after discharge were 65.6% and 76.2% at two years. Black patients, women, and patients with neurologic disability at discharge were more likely to be readmitted.

Because this is an observational study looking at a quality database of Medicare patients, it excludes patients at VA hospitals and non-Medicare facilities. This data excludes assessments of quality of life after discharge and health status among those with long-term survival, and does not include cause of death.

Bottom line: One-year survival following in-hospital cardiac arrest for patients over age 65 approaches 60% and decreases with increasing age, male sex, and black race.

Citation: Chan PS, Nallamothu BK, Krumholz HM, et al. Long-term outcomes in elderly survivors of in-hospital cardiac arrest. N Engl J Med. 2013;368:1019-1026.

Clinical question: What is the long-term outcome of elderly survivors of in-hospital cardiac arrest?

Background: Previous studies have examined in-hospital survival from in-hospital cardiac arrest but have not looked at long-term outcomes and readmission of in-hospital cardiac arrest survivors.

Study design: Retrospective cohort.

Setting: Acute-care hospitals that submitted data to the Get with the Guidelines—Resuscitation registry between 2000 and 2008.

Synopsis: Using the Get with the Guidelines—Resuscitation registry from 401 acute-care hospitals, data from 6,972 Medicare patients aged 65 years or older who had a pulseless in-hospital cardiac arrest and survived to discharge were analyzed. Survival rates were 82% at 30 days, 72% at three months, 58.5% at one year, and 49.6% at two years. Survival at three years was 43.5%, similar to patients discharged with heart failure.

One-year survival decreased with increasing age. Survival also decreased with black race (52.5% vs. 60.4% for white patients, P=0.001) and male sex (58.6% vs. 60.9% for women, P=0.03). Patients with mild or no neurologic disability at discharge had a higher survival rate at one year than patients with moderate, severe, or coma state. Readmission rates at one year after discharge were 65.6% and 76.2% at two years. Black patients, women, and patients with neurologic disability at discharge were more likely to be readmitted.

Because this is an observational study looking at a quality database of Medicare patients, it excludes patients at VA hospitals and non-Medicare facilities. This data excludes assessments of quality of life after discharge and health status among those with long-term survival, and does not include cause of death.

Bottom line: One-year survival following in-hospital cardiac arrest for patients over age 65 approaches 60% and decreases with increasing age, male sex, and black race.

Citation: Chan PS, Nallamothu BK, Krumholz HM, et al. Long-term outcomes in elderly survivors of in-hospital cardiac arrest. N Engl J Med. 2013;368:1019-1026.

Clinical question: What is the long-term outcome of elderly survivors of in-hospital cardiac arrest?

Background: Previous studies have examined in-hospital survival from in-hospital cardiac arrest but have not looked at long-term outcomes and readmission of in-hospital cardiac arrest survivors.

Study design: Retrospective cohort.

Setting: Acute-care hospitals that submitted data to the Get with the Guidelines—Resuscitation registry between 2000 and 2008.

Synopsis: Using the Get with the Guidelines—Resuscitation registry from 401 acute-care hospitals, data from 6,972 Medicare patients aged 65 years or older who had a pulseless in-hospital cardiac arrest and survived to discharge were analyzed. Survival rates were 82% at 30 days, 72% at three months, 58.5% at one year, and 49.6% at two years. Survival at three years was 43.5%, similar to patients discharged with heart failure.

One-year survival decreased with increasing age. Survival also decreased with black race (52.5% vs. 60.4% for white patients, P=0.001) and male sex (58.6% vs. 60.9% for women, P=0.03). Patients with mild or no neurologic disability at discharge had a higher survival rate at one year than patients with moderate, severe, or coma state. Readmission rates at one year after discharge were 65.6% and 76.2% at two years. Black patients, women, and patients with neurologic disability at discharge were more likely to be readmitted.

Because this is an observational study looking at a quality database of Medicare patients, it excludes patients at VA hospitals and non-Medicare facilities. This data excludes assessments of quality of life after discharge and health status among those with long-term survival, and does not include cause of death.

Bottom line: One-year survival following in-hospital cardiac arrest for patients over age 65 approaches 60% and decreases with increasing age, male sex, and black race.

Citation: Chan PS, Nallamothu BK, Krumholz HM, et al. Long-term outcomes in elderly survivors of in-hospital cardiac arrest. N Engl J Med. 2013;368:1019-1026.