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A Randomized Trial of Nighttime Physician Staffing in an Intensive Care Unit
The Journal of Emergency Medicine Comments: By understanding the microbiology of skin and soft tissue infections and targeting the most common bacteria—b-hemolytic strep in cellulitis and MRSA in abscess, providers can more thoughtfully make antibiotic decisions. These data demonstrate that this is currently not being done well, but also represent a very tangible way to change prescribing practice patterns in the emergency department. This practice could have important benefits for patients by decreasing side effects and costs of unnecessary medications. Limiting antibiotic prescriptions also has broader societal effects by helping to stave off the growth of antibiotic-resistant organisms. , EFFECT OF COMMUNICATION SKILLS TRAINING FOR RESIDENTS AND NURSE PRACTITIONERS ON QUALITY OF COMMUNICATION WITH PATIENTS WITH SERIOUS ILLNESS: A RANDOMIZED TRIAL. Curtis JR, Back AL, Kross, EK, et al. JAMA 2013;310: 2271–81. Effective communication with critically ill patients and their families is an important but frequently difficult skill for physicians. Previous observational studies suggest that communication about end-of-life care is associated with both increased ‘‘quality of life’’ and ‘‘quality of dying,’’ and that communication interventions for providers can further improve these patient-reported outcomes. This study randomized 472 new providers to receive eight sessions of simulationbased communication training or usual education and assessed the effect on patient and families’ reported quality of communication (QOC) and quality of end-of-life-care (QEOLC), and patient depressive symptoms. Ultimately, this intervention was not associated with a significant change in either QOC or QEOLC in either the patient or family groups. The intervention was associated with a small but statistically significant increase in depression scores among patients of the intervention group. There were some substantial limitations to this study. There were overall low response rates (44% of patients) and significantly lower rates for patients in hospice care, those with documented end-of-life care discussion, those > 80 years old, those with cancer, and family members of patients who died; groups that arguably would have had substantial benefit from these discussions with their physicians. The authors also raise the issue of difficulties of untrained patients being able to accurately and objectively rate clinician communication. Lastly, the evaluation period lasted 10 months, potentially introducing recall bias as a confounder and missed shorterterm benefits. [Avery MacKenzie, MD Denver Health Medical Center, Denver, CO] Comments: Communicating with critically ill patients in an honest, concise, and straightforward manner is an important skill for emergency physicians. However, this research does not support implementation of costly and time-consuming, simulation-based workshops to improve these skills in trainees. More research will likely need to be done to identify interventions that may improve provider proficiency in this important realm of patient care.
447 , COST-EFFECTIVENESS OF LOW-MOLECULARWEIGHT HEPARIN COMPARED WITH ASPIRIN FOR PROPHYLAXIS AGAINST VENOUS THROMBOEMBOLISM AFTER TOTAL JOINT ARTHROPLASTY. Schousboe J, Brown G. J Bone Joint Surg Am 2013; 95: 1256–64. There is a high rate of venous thromboembolic (VTE) disease in patients undergoing total hip or knee replacements, and there is controversy over which prophylactic anticoagulant is appropriate for this high-risk population. The authors sought to compare VTE prophylaxis with 14 days of oral aspirin vs. 14 days of low-molecular-weight heparin (LMWH) with respect to lifetime costs, gained quality-adjusted life years (QALYs) and cost per QALY by using a Markov cohort of patients without history of VTE that underwent either total hip arthroplasty (THA) or total knee arthroplasty (TKA). Using these data, the authors performed a probability sensitivity analysis and found a decreased probability of LMWH being cost effective for patients undergoing THA and for those 80 years old or higher undergoing TKA. The authors conclude that in patients undergoing THA without a history of VTE, aspirin is adequate VTE prophylaxis, but in similar patients undergoing TKA, the anticoagulant of choice is age dependent and still unclear. [Joseph Hemerka, MD Denver Health Medical Center, Denver, CO] Comments: Emergency departments commonly see patients with VTE disease after undergoing THA or TKA. This study did not directly address the efficacy of aspirin vs. LMWH in VTE prevention, so it should not be used to change our diagnostic decision-making in these patients. Additionally, there is a disclosure made that one or more authors had a financial relationship that could be considered a bias. Overall, although both aspirin and LWMH are used in VTE prophylaxis, it seems that aspirin may be an overall cost-effective alternative in patients without a history of VTE undergoing THA and in younger patients undergoing TKA. , A RANDOMIZED TRIAL OF NIGHTTIME PHYSICIAN STAFFING IN AN INTENSIVE CARE UNIT. Kerlin MP, Small DS, Cooney E, et al. N Engl J Med 2013; 368: 2201–9. Intensive care units (ICUs) are increasingly seeking 24-h attending intensivist coverage. Although intuitively it would seem that increased attending coverage would improve patient outcomes, this has yet to be studied. To study this effect, the authors at a single academic medical ICU conducted a 1-year randomized study in which attending intensivists were scheduled to work a block of seven consecutive overnight shifts (to encompass 24-h coverage) vs. standard staffing (resident coverage with attending/fellow available by telephone). The primary outcome was length of stay in the ICU, for which there was no significant difference between groups (rate ratio for ICU discharge, 0.98; 95% confidence interval 0.88–1.09). Secondary outcomes included total hospital stay, ICU and in-hospital mortality, discharge to home from hospital, and ICU readmissions (within 48 h), all of which did not have significant changes.
448 The authors conclude that at an academic medical ICU, having an overnight attending intensivist present did not improve patient outcomes. [Joseph Hemerka, MD Denver Health Medical Center, Denver, CO] Comments: In conjunction with the shortage of physicians nationally, there has been a push to increase overnight attending intensivist coverage in intensive care units, with limited data proving its effect on patient outcomes. This study argues there was not a statistically significant change in outcomes with 24-h attending coverage. Although interesting, it only addresses a single academic medical ICU, excluding surgical/transplant patients. Additionally, this institution had resident coverage 24 h a day, which is not a feasible option in community settings. Although limited in generalizability, this study adds data to an area with a dearth of knowledge. , EFFECT OF VIDEO LARYNGOSCOPY ON TRAUMA PATIENT SURVIVAL: A RANDOMIZED CONTROLLED TRIAL. Yeatts DJ, Dutton RP, Hu PF, et al. J Trauma Acute Care Surg 2013;75:212–9. Direct laryngoscopy (DL) has been the standard care for controlling the emergent airway, however, with the advent of video laryngoscopy (VL), this practice has come into question. To compare DL vs. VL, the authors conducted a prospective controlled clinical trial in trauma patients at a single Level I trauma center in which 898 consecutive adult patients were randomized to undergo either DL or VL (largely by junior/senior Emergency Medicine or Anesthesiology residents) with the Glidescope device. Two hundred seventy-five of the eligible patients were excluded from the study, largely due to attending physician discretion. The primary outcome was survival, for
Abstracts which there was no significant difference between groups (VL 91% vs. DL 93%, p = 0.43). Within a smaller retrospectively obtained cohort of patients with severe traumatic brain injury (TBI), there was a significant increase in mortality of patients who underwent VL vs. DL (30% vs. 14%, respectively, p = 0.047). Secondary outcomes showed median time to intubation to be 56 s in the VL group, vs. 40 s in the DL group (p < 0.001), and there was no significant difference in first-pass success between the two groups. Again, in the subset of patients with severe TBI, median time to intubation was higher in the VL vs. DL group (74 s vs. 65 s, respectively, p < 0.003), and there was a higher rate of desaturations in the VL group vs. the DL group. The authors conclude that there was no significant difference in overall mortality in adult trauma patients emergently intubated with VL vs. DL, however, there was an increase in time to intubation with VL and, in severe TBI patients, an increase in significant desaturations and mortality. [Joseph Hemerka, MD Denver Health Medical Center, Denver, CO] Comments: At many institutions, video laryngoscopy is quickly becoming the new standard of care when emergent airway control is required. This is one of the few prospective studies comparing direct vs. video laryngoscopy, yet it has several major flaws. Notably, nearly 30% of patients were not included in the randomization due to attending physician preference (undisclosed reasons). Additionally, although the Glidescope is a common video laryngoscope, other video laryngoscopes with a less acute angle exist and are commonly used at other institutions. Although it has significant limitations, this article adds to growing literature comparing direct laryngoscopy vs. video laryngoscopy, and will need to be followed by more studies to further elucidate the differences between these intubation modalities.
447 , COST-EFFECTIVENESS OF LOW-MOLECULARWEIGHT HEPARIN COMPARED WITH ASPIRIN FOR PROPHYLAXIS AGAINST VENOUS THROMBOEMBOLISM AFTER TOTAL JOINT ARTHROPLASTY. Schousboe J, Brown G. J Bone Joint Surg Am 2013; 95: 1256–64. There is a high rate of venous thromboembolic (VTE) disease in patients undergoing total hip or knee replacements, and there is controversy over which prophylactic anticoagulant is appropriate for this high-risk population. The authors sought to compare VTE prophylaxis with 14 days of oral aspirin vs. 14 days of low-molecular-weight heparin (LMWH) with respect to lifetime costs, gained quality-adjusted life years (QALYs) and cost per QALY by using a Markov cohort of patients without history of VTE that underwent either total hip arthroplasty (THA) or total knee arthroplasty (TKA). Using these data, the authors performed a probability sensitivity analysis and found a decreased probability of LMWH being cost effective for patients undergoing THA and for those 80 years old or higher undergoing TKA. The authors conclude that in patients undergoing THA without a history of VTE, aspirin is adequate VTE prophylaxis, but in similar patients undergoing TKA, the anticoagulant of choice is age dependent and still unclear. [Joseph Hemerka, MD Denver Health Medical Center, Denver, CO] Comments: Emergency departments commonly see patients with VTE disease after undergoing THA or TKA. This study did not directly address the efficacy of aspirin vs. LMWH in VTE prevention, so it should not be used to change our diagnostic decision-making in these patients. Additionally, there is a disclosure made that one or more authors had a financial relationship that could be considered a bias. Overall, although both aspirin and LWMH are used in VTE prophylaxis, it seems that aspirin may be an overall cost-effective alternative in patients without a history of VTE undergoing THA and in younger patients undergoing TKA. , A RANDOMIZED TRIAL OF NIGHTTIME PHYSICIAN STAFFING IN AN INTENSIVE CARE UNIT. Kerlin MP, Small DS, Cooney E, et al. N Engl J Med 2013; 368: 2201–9. Intensive care units (ICUs) are increasingly seeking 24-h attending intensivist coverage. Although intuitively it would seem that increased attending coverage would improve patient outcomes, this has yet to be studied. To study this effect, the authors at a single academic medical ICU conducted a 1-year randomized study in which attending intensivists were scheduled to work a block of seven consecutive overnight shifts (to encompass 24-h coverage) vs. standard staffing (resident coverage with attending/fellow available by telephone). The primary outcome was length of stay in the ICU, for which there was no significant difference between groups (rate ratio for ICU discharge, 0.98; 95% confidence interval 0.88–1.09). Secondary outcomes included total hospital stay, ICU and in-hospital mortality, discharge to home from hospital, and ICU readmissions (within 48 h), all of which did not have significant changes.
448 The authors conclude that at an academic medical ICU, having an overnight attending intensivist present did not improve patient outcomes. [Joseph Hemerka, MD Denver Health Medical Center, Denver, CO] Comments: In conjunction with the shortage of physicians nationally, there has been a push to increase overnight attending intensivist coverage in intensive care units, with limited data proving its effect on patient outcomes. This study argues there was not a statistically significant change in outcomes with 24-h attending coverage. Although interesting, it only addresses a single academic medical ICU, excluding surgical/transplant patients. Additionally, this institution had resident coverage 24 h a day, which is not a feasible option in community settings. Although limited in generalizability, this study adds data to an area with a dearth of knowledge. , EFFECT OF VIDEO LARYNGOSCOPY ON TRAUMA PATIENT SURVIVAL: A RANDOMIZED CONTROLLED TRIAL. Yeatts DJ, Dutton RP, Hu PF, et al. J Trauma Acute Care Surg 2013;75:212–9. Direct laryngoscopy (DL) has been the standard care for controlling the emergent airway, however, with the advent of video laryngoscopy (VL), this practice has come into question. To compare DL vs. VL, the authors conducted a prospective controlled clinical trial in trauma patients at a single Level I trauma center in which 898 consecutive adult patients were randomized to undergo either DL or VL (largely by junior/senior Emergency Medicine or Anesthesiology residents) with the Glidescope device. Two hundred seventy-five of the eligible patients were excluded from the study, largely due to attending physician discretion. The primary outcome was survival, for
Abstracts which there was no significant difference between groups (VL 91% vs. DL 93%, p = 0.43). Within a smaller retrospectively obtained cohort of patients with severe traumatic brain injury (TBI), there was a significant increase in mortality of patients who underwent VL vs. DL (30% vs. 14%, respectively, p = 0.047). Secondary outcomes showed median time to intubation to be 56 s in the VL group, vs. 40 s in the DL group (p < 0.001), and there was no significant difference in first-pass success between the two groups. Again, in the subset of patients with severe TBI, median time to intubation was higher in the VL vs. DL group (74 s vs. 65 s, respectively, p < 0.003), and there was a higher rate of desaturations in the VL group vs. the DL group. The authors conclude that there was no significant difference in overall mortality in adult trauma patients emergently intubated with VL vs. DL, however, there was an increase in time to intubation with VL and, in severe TBI patients, an increase in significant desaturations and mortality. [Joseph Hemerka, MD Denver Health Medical Center, Denver, CO] Comments: At many institutions, video laryngoscopy is quickly becoming the new standard of care when emergent airway control is required. This is one of the few prospective studies comparing direct vs. video laryngoscopy, yet it has several major flaws. Notably, nearly 30% of patients were not included in the randomization due to attending physician preference (undisclosed reasons). Additionally, although the Glidescope is a common video laryngoscope, other video laryngoscopes with a less acute angle exist and are commonly used at other institutions. Although it has significant limitations, this article adds to growing literature comparing direct laryngoscopy vs. video laryngoscopy, and will need to be followed by more studies to further elucidate the differences between these intubation modalities.