A new study evaluating outcomes for hospitals participating in the American Heart Association’s Get with the Guidelines program found no correlation between high performance on adhering to measures and care standards for acute myocardial infarction and for heart failure despite overlap between the sets of care processes (J Am Coll Cardio. 2011;58:637-644).

A total of 400,000 heart patients were studied, and 283 participating hospitals were stratified into thirds based on their adherence to core quality measures for each disease, with the upper third labeled superior in performance. Lead author Tracy Wang, MD, MHS, MSc, of the Duke Clinical Research Institute in Durham, N.C., and colleagues found that superior performance for only one of the two diseases led to such end-result outcomes as in-hospital mortality that were no better than for hospitals that were not high performers for either condition. But hospitals with superior performance for both conditions had lower in-hospital mortality rates.

“Perhaps quality is more than just following checklists,” Dr. Wang says. “There’s something special about these high-performing hospitals across the board, with better QI, perhaps a little more investment in infrastructure for quality.”

This result, Dr. Wang says, should give ammunition for hospitalists and other physicians to go to their hospital administrators to request more investment in quality improvement overall, not just for specific conditions.

A new study evaluating outcomes for hospitals participating in the American Heart Association’s Get with the Guidelines program found no correlation between high performance on adhering to measures and care standards for acute myocardial infarction and for heart failure despite overlap between the sets of care processes (J Am Coll Cardio. 2011;58:637-644).

A total of 400,000 heart patients were studied, and 283 participating hospitals were stratified into thirds based on their adherence to core quality measures for each disease, with the upper third labeled superior in performance. Lead author Tracy Wang, MD, MHS, MSc, of the Duke Clinical Research Institute in Durham, N.C., and colleagues found that superior performance for only one of the two diseases led to such end-result outcomes as in-hospital mortality that were no better than for hospitals that were not high performers for either condition. But hospitals with superior performance for both conditions had lower in-hospital mortality rates.

“Perhaps quality is more than just following checklists,” Dr. Wang says. “There’s something special about these high-performing hospitals across the board, with better QI, perhaps a little more investment in infrastructure for quality.”

This result, Dr. Wang says, should give ammunition for hospitalists and other physicians to go to their hospital administrators to request more investment in quality improvement overall, not just for specific conditions.

A new study evaluating outcomes for hospitals participating in the American Heart Association’s Get with the Guidelines program found no correlation between high performance on adhering to measures and care standards for acute myocardial infarction and for heart failure despite overlap between the sets of care processes (J Am Coll Cardio. 2011;58:637-644).

A total of 400,000 heart patients were studied, and 283 participating hospitals were stratified into thirds based on their adherence to core quality measures for each disease, with the upper third labeled superior in performance. Lead author Tracy Wang, MD, MHS, MSc, of the Duke Clinical Research Institute in Durham, N.C., and colleagues found that superior performance for only one of the two diseases led to such end-result outcomes as in-hospital mortality that were no better than for hospitals that were not high performers for either condition. But hospitals with superior performance for both conditions had lower in-hospital mortality rates.

“Perhaps quality is more than just following checklists,” Dr. Wang says. “There’s something special about these high-performing hospitals across the board, with better QI, perhaps a little more investment in infrastructure for quality.”

This result, Dr. Wang says, should give ammunition for hospitalists and other physicians to go to their hospital administrators to request more investment in quality improvement overall, not just for specific conditions.

When James Davis, BSN, RN, CCRN, CIC, first began his nursing career, central venous catheters were widely considered a welcome convenience. “And then we found out that if patients don’t need that line to save their lives, it could kill them, and we need to get them out,” says Davis, now a senior infection prevention analyst with the Pennsylvania Patient Safety Authority in Harrisburg.

Many facilities have dramatically lowered their rates of central-line-associated bloodstream infections (CLABSIs) through a bundled approach focused on proper insertion protocols. But as Davis and other researchers have found, that’s not nearly enough. “If you listen to the infection prevention specialists out there, they’re saying, ‘Well, we’ve done all this, we’ve gotten good results, but there has to be something else because we’re seeing reductions but we still have these infections,’” he says.

That something else, as he discovered in a recent study, may very well be the breakdown of central-line maintenance that causes a late-onset CLABSI, especially after five days post-insertion. From analyzing reports submitted to the National Healthcare Safety Network by 104 acute-care facilities in Pennsylvania, Davis found that nearly 72% of the reported CLABSIs in 2010 were late in onset, occurring after the fifth day.¹

CLABSI expert Marcia Ryder, PhD, MS, RN, research scientist at Ryder Science in San Marcos, Calif., says the study is the first to obtain a clear picture of the average time to event from a large hospital-based data set. Dr. Ryder says the results also strongly suggest that most CLABSIs are caused by maintenance failures and bacterial biofilm formation in the catheter’s internal lumen rather than insertion problems and the presence of an extraluminal biofilm.

The study may help reinforce a message that many CLABSI experts are already sharing with their colleagues. “I like to say that the most important risk factor for a CLABSI is the presence of a central line,” says Sheri Chernetsky Tejedor, MD, SFHM, assistant professor in the division of hospital medicine at Emory University School of Medicine in Atlanta. “If a CVC is not needed, it needs to be removed. The longer they stay in, the higher the cumulative risk of CLABSI.

Current Practices Not Enough

Dr. Ryder says the new research highlights the absurdity of efforts that focus primarily on ICUs. “We’ve always been doing surveillance and monitoring in critical-care units, which is not where the major problem is,” she says. In the U.S., the average length of stay in a critical-care unit is roughly four days. “If most infections are happening after that, they’re never even being picked up, and they’re saying, ‘Well, we have zero infections,’ when indeed they don’t,” she says.

Davis says infection-prevention specialists—hospitalists included—should be regularly reviewing their facility’s central-line-maintenance practices. Perhaps the most important first step is to begin recording both the catheter insertion date and the infection date—line items that are still voluntary in many states like Pennsylvania. With that critical data, studies by Davis and other researchers can provide a better sense of CLABSI origins. “Can we put a fulcrum between insertion and maintenance and show facilities how to look to see which way their scale is tipping?” he asks. If so, those facilities will know how to reallocate their resources accordingly.

Bryn Nelson, PhD, is a freelance writer based in Seattle.

Reference

1. Davis J. Central-line associated bloodstream infection: comprehensive, data-driven prevention. Pa Patient Saf Advis. 2011;8:100-105.

When James Davis, BSN, RN, CCRN, CIC, first began his nursing career, central venous catheters were widely considered a welcome convenience. “And then we found out that if patients don’t need that line to save their lives, it could kill them, and we need to get them out,” says Davis, now a senior infection prevention analyst with the Pennsylvania Patient Safety Authority in Harrisburg.

Many facilities have dramatically lowered their rates of central-line-associated bloodstream infections (CLABSIs) through a bundled approach focused on proper insertion protocols. But as Davis and other researchers have found, that’s not nearly enough. “If you listen to the infection prevention specialists out there, they’re saying, ‘Well, we’ve done all this, we’ve gotten good results, but there has to be something else because we’re seeing reductions but we still have these infections,’” he says.

That something else, as he discovered in a recent study, may very well be the breakdown of central-line maintenance that causes a late-onset CLABSI, especially after five days post-insertion. From analyzing reports submitted to the National Healthcare Safety Network by 104 acute-care facilities in Pennsylvania, Davis found that nearly 72% of the reported CLABSIs in 2010 were late in onset, occurring after the fifth day.¹

CLABSI expert Marcia Ryder, PhD, MS, RN, research scientist at Ryder Science in San Marcos, Calif., says the study is the first to obtain a clear picture of the average time to event from a large hospital-based data set. Dr. Ryder says the results also strongly suggest that most CLABSIs are caused by maintenance failures and bacterial biofilm formation in the catheter’s internal lumen rather than insertion problems and the presence of an extraluminal biofilm.

The study may help reinforce a message that many CLABSI experts are already sharing with their colleagues. “I like to say that the most important risk factor for a CLABSI is the presence of a central line,” says Sheri Chernetsky Tejedor, MD, SFHM, assistant professor in the division of hospital medicine at Emory University School of Medicine in Atlanta. “If a CVC is not needed, it needs to be removed. The longer they stay in, the higher the cumulative risk of CLABSI.

Current Practices Not Enough

Dr. Ryder says the new research highlights the absurdity of efforts that focus primarily on ICUs. “We’ve always been doing surveillance and monitoring in critical-care units, which is not where the major problem is,” she says. In the U.S., the average length of stay in a critical-care unit is roughly four days. “If most infections are happening after that, they’re never even being picked up, and they’re saying, ‘Well, we have zero infections,’ when indeed they don’t,” she says.

Davis says infection-prevention specialists—hospitalists included—should be regularly reviewing their facility’s central-line-maintenance practices. Perhaps the most important first step is to begin recording both the catheter insertion date and the infection date—line items that are still voluntary in many states like Pennsylvania. With that critical data, studies by Davis and other researchers can provide a better sense of CLABSI origins. “Can we put a fulcrum between insertion and maintenance and show facilities how to look to see which way their scale is tipping?” he asks. If so, those facilities will know how to reallocate their resources accordingly.

Bryn Nelson, PhD, is a freelance writer based in Seattle.

Reference

1. Davis J. Central-line associated bloodstream infection: comprehensive, data-driven prevention. Pa Patient Saf Advis. 2011;8:100-105.

When James Davis, BSN, RN, CCRN, CIC, first began his nursing career, central venous catheters were widely considered a welcome convenience. “And then we found out that if patients don’t need that line to save their lives, it could kill them, and we need to get them out,” says Davis, now a senior infection prevention analyst with the Pennsylvania Patient Safety Authority in Harrisburg.

Many facilities have dramatically lowered their rates of central-line-associated bloodstream infections (CLABSIs) through a bundled approach focused on proper insertion protocols. But as Davis and other researchers have found, that’s not nearly enough. “If you listen to the infection prevention specialists out there, they’re saying, ‘Well, we’ve done all this, we’ve gotten good results, but there has to be something else because we’re seeing reductions but we still have these infections,’” he says.

That something else, as he discovered in a recent study, may very well be the breakdown of central-line maintenance that causes a late-onset CLABSI, especially after five days post-insertion. From analyzing reports submitted to the National Healthcare Safety Network by 104 acute-care facilities in Pennsylvania, Davis found that nearly 72% of the reported CLABSIs in 2010 were late in onset, occurring after the fifth day.¹

CLABSI expert Marcia Ryder, PhD, MS, RN, research scientist at Ryder Science in San Marcos, Calif., says the study is the first to obtain a clear picture of the average time to event from a large hospital-based data set. Dr. Ryder says the results also strongly suggest that most CLABSIs are caused by maintenance failures and bacterial biofilm formation in the catheter’s internal lumen rather than insertion problems and the presence of an extraluminal biofilm.

The study may help reinforce a message that many CLABSI experts are already sharing with their colleagues. “I like to say that the most important risk factor for a CLABSI is the presence of a central line,” says Sheri Chernetsky Tejedor, MD, SFHM, assistant professor in the division of hospital medicine at Emory University School of Medicine in Atlanta. “If a CVC is not needed, it needs to be removed. The longer they stay in, the higher the cumulative risk of CLABSI.

Current Practices Not Enough

Dr. Ryder says the new research highlights the absurdity of efforts that focus primarily on ICUs. “We’ve always been doing surveillance and monitoring in critical-care units, which is not where the major problem is,” she says. In the U.S., the average length of stay in a critical-care unit is roughly four days. “If most infections are happening after that, they’re never even being picked up, and they’re saying, ‘Well, we have zero infections,’ when indeed they don’t,” she says.

Davis says infection-prevention specialists—hospitalists included—should be regularly reviewing their facility’s central-line-maintenance practices. Perhaps the most important first step is to begin recording both the catheter insertion date and the infection date—line items that are still voluntary in many states like Pennsylvania. With that critical data, studies by Davis and other researchers can provide a better sense of CLABSI origins. “Can we put a fulcrum between insertion and maintenance and show facilities how to look to see which way their scale is tipping?” he asks. If so, those facilities will know how to reallocate their resources accordingly.

Bryn Nelson, PhD, is a freelance writer based in Seattle.

Reference

1. Davis J. Central-line associated bloodstream infection: comprehensive, data-driven prevention. Pa Patient Saf Advis. 2011;8:100-105.

Research that shows 1 in 3 adult patients does not see a physician within 30 days of discharge is the latest sign that more communication is needed between hospital physicians their community colleagues, a researcher says.

A report from the National Institute for Health Care Reform (NIHCR) found that after 90 days, 17.6% of adults still have not seen a physician, nurse practitioner, or physician assistant, says Anna Sommers, PhD, senior health researcher at the Center for Studying Health System Change, which conducts research for NIHCR. She adds that better communication between hospitalists and PCPs or specialists can be encouraged by important health information technology (HIT), but the process isn't a simple fix.

"That's not just about getting a shared medical record in place," she adds. "A medical record, even for just one inpatient stay, can be large. How does the doctor sift through all that? ... [Technology] can be part of the solution, but I think everyone is still learning how to use the technology and developing interfaces that are useful to the users. It's an evolving process.”

Hospitalists have helped address transitional-care issues with initiatives including post-discharge clinics, but more work needs to be done, Dr. Sommers says. She adds that the depth of the readmission issue is particularly striking as the research found that non-elderly adults with public coverage, a population that historically has higher rates of chronic conditions, were no more likely to see a doctor with 30 days of discharge than a person with private insurance.

"This problem is occurring all over the place," Dr. Sommers says. "It's a systematic problem, not a problem of one population in the health system."

Research that shows 1 in 3 adult patients does not see a physician within 30 days of discharge is the latest sign that more communication is needed between hospital physicians their community colleagues, a researcher says.

A report from the National Institute for Health Care Reform (NIHCR) found that after 90 days, 17.6% of adults still have not seen a physician, nurse practitioner, or physician assistant, says Anna Sommers, PhD, senior health researcher at the Center for Studying Health System Change, which conducts research for NIHCR. She adds that better communication between hospitalists and PCPs or specialists can be encouraged by important health information technology (HIT), but the process isn't a simple fix.

"That's not just about getting a shared medical record in place," she adds. "A medical record, even for just one inpatient stay, can be large. How does the doctor sift through all that? ... [Technology] can be part of the solution, but I think everyone is still learning how to use the technology and developing interfaces that are useful to the users. It's an evolving process.”

Hospitalists have helped address transitional-care issues with initiatives including post-discharge clinics, but more work needs to be done, Dr. Sommers says. She adds that the depth of the readmission issue is particularly striking as the research found that non-elderly adults with public coverage, a population that historically has higher rates of chronic conditions, were no more likely to see a doctor with 30 days of discharge than a person with private insurance.

"This problem is occurring all over the place," Dr. Sommers says. "It's a systematic problem, not a problem of one population in the health system."

Research that shows 1 in 3 adult patients does not see a physician within 30 days of discharge is the latest sign that more communication is needed between hospital physicians their community colleagues, a researcher says.

A report from the National Institute for Health Care Reform (NIHCR) found that after 90 days, 17.6% of adults still have not seen a physician, nurse practitioner, or physician assistant, says Anna Sommers, PhD, senior health researcher at the Center for Studying Health System Change, which conducts research for NIHCR. She adds that better communication between hospitalists and PCPs or specialists can be encouraged by important health information technology (HIT), but the process isn't a simple fix.

"That's not just about getting a shared medical record in place," she adds. "A medical record, even for just one inpatient stay, can be large. How does the doctor sift through all that? ... [Technology] can be part of the solution, but I think everyone is still learning how to use the technology and developing interfaces that are useful to the users. It's an evolving process.”

Hospitalists have helped address transitional-care issues with initiatives including post-discharge clinics, but more work needs to be done, Dr. Sommers says. She adds that the depth of the readmission issue is particularly striking as the research found that non-elderly adults with public coverage, a population that historically has higher rates of chronic conditions, were no more likely to see a doctor with 30 days of discharge than a person with private insurance.

"This problem is occurring all over the place," Dr. Sommers says. "It's a systematic problem, not a problem of one population in the health system."

Improving discharge processes calls for hospitalists to be the voice of change within their facilities, Michelle Mourad, MD, hospitalist and director of quality at the University of California at San Francisco Medical Center, said at UCSF's 19th annual Management of the Hospitalized Patient conference in San Francisco.

"Be the role model. Be the one who always does discharges right," she said in a breakout session focused on discharge improvement.

Dr. Mourad and co-presenter Ryan Greyson, MD, MHS, MA, both sit on UCSF's multidisciplinary Discharge Improvement Team, an approach they recommend to other hospitals. They also say fixing hospital discharges won't be easy, and it requires an individualized approach tailored to each facility and its unique culture.

"Think about the little things you can do. Figure out which steps are needed for safe discharges," she added.

UCSF has implemented a post-discharge hotline for patients to call with follow-up medical problems, and also makes outgoing follow-up calls. A discharge pharmacist performs medication reconciliation for patients with high-risk medications or multiple prescriptions.

A folder called "Your Discharge Information," which encapsulates the patient's medications, discharge plans, follow-up appointments, and the like, goes home with each patient. Unless the patient is known to be reliable, hospital staff also schedule the initial post-discharge medical appointment.

UCSF has developed relationships with local home health agencies, encouraging them to qualify patients with complex needs, including multiple prescriptions, for home health coverage. The home-care nurse then revisits medication reconciliation once the patient is settled back into the home setting. The medical center is developing an agreement with the pharmacy across the street to share the costs of uncovered prescriptions for patients who can't afford to buy them, and often sends patients home with prescription supplies ranging from seven to 30 days, depending on diagnosis.

UCSF's discharge improvements have made an impact on internal-medicine readmission rates. The rate of readmission for patients under age 65 was 16.5% in calendar year 2008, 15.5% in 2009, and 13.2% in 2010.

"Discharge has to be an institutional priority," Dr. Mourad concluded. It requires support from the top down and from the bottom up. It will be hard to succeed, "unless the whole institution believes that it is important."

Improving discharge processes calls for hospitalists to be the voice of change within their facilities, Michelle Mourad, MD, hospitalist and director of quality at the University of California at San Francisco Medical Center, said at UCSF's 19th annual Management of the Hospitalized Patient conference in San Francisco.

"Be the role model. Be the one who always does discharges right," she said in a breakout session focused on discharge improvement.

Dr. Mourad and co-presenter Ryan Greyson, MD, MHS, MA, both sit on UCSF's multidisciplinary Discharge Improvement Team, an approach they recommend to other hospitals. They also say fixing hospital discharges won't be easy, and it requires an individualized approach tailored to each facility and its unique culture.

"Think about the little things you can do. Figure out which steps are needed for safe discharges," she added.

UCSF has implemented a post-discharge hotline for patients to call with follow-up medical problems, and also makes outgoing follow-up calls. A discharge pharmacist performs medication reconciliation for patients with high-risk medications or multiple prescriptions.

A folder called "Your Discharge Information," which encapsulates the patient's medications, discharge plans, follow-up appointments, and the like, goes home with each patient. Unless the patient is known to be reliable, hospital staff also schedule the initial post-discharge medical appointment.

UCSF has developed relationships with local home health agencies, encouraging them to qualify patients with complex needs, including multiple prescriptions, for home health coverage. The home-care nurse then revisits medication reconciliation once the patient is settled back into the home setting. The medical center is developing an agreement with the pharmacy across the street to share the costs of uncovered prescriptions for patients who can't afford to buy them, and often sends patients home with prescription supplies ranging from seven to 30 days, depending on diagnosis.

UCSF's discharge improvements have made an impact on internal-medicine readmission rates. The rate of readmission for patients under age 65 was 16.5% in calendar year 2008, 15.5% in 2009, and 13.2% in 2010.

"Discharge has to be an institutional priority," Dr. Mourad concluded. It requires support from the top down and from the bottom up. It will be hard to succeed, "unless the whole institution believes that it is important."

Improving discharge processes calls for hospitalists to be the voice of change within their facilities, Michelle Mourad, MD, hospitalist and director of quality at the University of California at San Francisco Medical Center, said at UCSF's 19th annual Management of the Hospitalized Patient conference in San Francisco.

"Be the role model. Be the one who always does discharges right," she said in a breakout session focused on discharge improvement.

Dr. Mourad and co-presenter Ryan Greyson, MD, MHS, MA, both sit on UCSF's multidisciplinary Discharge Improvement Team, an approach they recommend to other hospitals. They also say fixing hospital discharges won't be easy, and it requires an individualized approach tailored to each facility and its unique culture.

"Think about the little things you can do. Figure out which steps are needed for safe discharges," she added.

UCSF has implemented a post-discharge hotline for patients to call with follow-up medical problems, and also makes outgoing follow-up calls. A discharge pharmacist performs medication reconciliation for patients with high-risk medications or multiple prescriptions.

A folder called "Your Discharge Information," which encapsulates the patient's medications, discharge plans, follow-up appointments, and the like, goes home with each patient. Unless the patient is known to be reliable, hospital staff also schedule the initial post-discharge medical appointment.

UCSF has developed relationships with local home health agencies, encouraging them to qualify patients with complex needs, including multiple prescriptions, for home health coverage. The home-care nurse then revisits medication reconciliation once the patient is settled back into the home setting. The medical center is developing an agreement with the pharmacy across the street to share the costs of uncovered prescriptions for patients who can't afford to buy them, and often sends patients home with prescription supplies ranging from seven to 30 days, depending on diagnosis.

UCSF's discharge improvements have made an impact on internal-medicine readmission rates. The rate of readmission for patients under age 65 was 16.5% in calendar year 2008, 15.5% in 2009, and 13.2% in 2010.

"Discharge has to be an institutional priority," Dr. Mourad concluded. It requires support from the top down and from the bottom up. It will be hard to succeed, "unless the whole institution believes that it is important."

The recent surge in attention to catheter-associated urinary tract infections (CAUTIs) has increased the focus on both preventing and removing inappropriate catheterizations. Ironically, one outcome rate currently reported by hospitals—the number of infections per 1,000 catheter days—could unfairly punish those facilities that are doing the most to address the problem.

You may end up having a paradoxical increased rate of CAUTI after your successful initiative has reduced catheter use.

—Sanjay Saint, MD, MPH, FHM, professor of internal medicine, University of Michigan, Ann Arbor VA Medical Center

“If your focus is on not putting in the catheter or removing a catheter as soon as possible, you now reduce that denominator of catheter days,” explains Sanjay Saint, MD, MPH, FHM, professor of internal medicine at the University of Michigan and the Ann Arbor VA Medical Center. “The only people who now get a catheter in your hospital are those who are pretty sick; therefore, they need a catheter. These people, because of their underlying sickness, are more likely to have an infection, so you may end up having a paradoxical increased rate of CAUTI after your successful initiative has reduced catheter use.”

Using the wrong denominator, in other words, could defeat the whole point: reducing infections by reducing catheter use.

“If we’re going to publicly report data, we have to make sure that the data we’re reporting and the metrics that we’re using are actually the best metrics for the intended purpose,” Dr. Saint says.

For quality-improvement (QI) efforts, his recommendation is to use 10,000 patient days as a more appropriate denominator.

The recent surge in attention to catheter-associated urinary tract infections (CAUTIs) has increased the focus on both preventing and removing inappropriate catheterizations. Ironically, one outcome rate currently reported by hospitals—the number of infections per 1,000 catheter days—could unfairly punish those facilities that are doing the most to address the problem.

You may end up having a paradoxical increased rate of CAUTI after your successful initiative has reduced catheter use.

—Sanjay Saint, MD, MPH, FHM, professor of internal medicine, University of Michigan, Ann Arbor VA Medical Center

“If your focus is on not putting in the catheter or removing a catheter as soon as possible, you now reduce that denominator of catheter days,” explains Sanjay Saint, MD, MPH, FHM, professor of internal medicine at the University of Michigan and the Ann Arbor VA Medical Center. “The only people who now get a catheter in your hospital are those who are pretty sick; therefore, they need a catheter. These people, because of their underlying sickness, are more likely to have an infection, so you may end up having a paradoxical increased rate of CAUTI after your successful initiative has reduced catheter use.”

Using the wrong denominator, in other words, could defeat the whole point: reducing infections by reducing catheter use.

“If we’re going to publicly report data, we have to make sure that the data we’re reporting and the metrics that we’re using are actually the best metrics for the intended purpose,” Dr. Saint says.

For quality-improvement (QI) efforts, his recommendation is to use 10,000 patient days as a more appropriate denominator.

The recent surge in attention to catheter-associated urinary tract infections (CAUTIs) has increased the focus on both preventing and removing inappropriate catheterizations. Ironically, one outcome rate currently reported by hospitals—the number of infections per 1,000 catheter days—could unfairly punish those facilities that are doing the most to address the problem.

You may end up having a paradoxical increased rate of CAUTI after your successful initiative has reduced catheter use.

—Sanjay Saint, MD, MPH, FHM, professor of internal medicine, University of Michigan, Ann Arbor VA Medical Center

“If your focus is on not putting in the catheter or removing a catheter as soon as possible, you now reduce that denominator of catheter days,” explains Sanjay Saint, MD, MPH, FHM, professor of internal medicine at the University of Michigan and the Ann Arbor VA Medical Center. “The only people who now get a catheter in your hospital are those who are pretty sick; therefore, they need a catheter. These people, because of their underlying sickness, are more likely to have an infection, so you may end up having a paradoxical increased rate of CAUTI after your successful initiative has reduced catheter use.”

Using the wrong denominator, in other words, could defeat the whole point: reducing infections by reducing catheter use.

“If we’re going to publicly report data, we have to make sure that the data we’re reporting and the metrics that we’re using are actually the best metrics for the intended purpose,” Dr. Saint says.

For quality-improvement (QI) efforts, his recommendation is to use 10,000 patient days as a more appropriate denominator.

Because “med rec” is a responsibility shared by providers, patients, and families, it’s important to engage everyone in the process.

Although the patient is—and should be, if capable—the ultimate owner of the correct healthcare record, “We have a responsibility as healthcare providers to help them be successful,” says Blake Lesselroth, MD, assistant professor of medicine at Oregon Health Sciences University and director of the Portland Patient Safety Center of Inquiry at the Portland VA Medical Center. “We haven’t done that.”

Hospitals and healthcare systems use varied strategies for including and empowering patients in the med-rec process:

• The Joint Commission launched its “Speak Up” program (PDF), which gives patients tools to help avoid mistakes with their medications.
• Last year, Southern California Kaiser Permanente rolled out its “medicine in a bag” initiative, according to hospitalist David Wong, MD. Patients are instructed to bring all of their medications (in their respective containers) to the hospital when they are admitted. Then, as the med-rec process is completed, medications are placed in green (take these meds), red (stop these meds), and yellow bags (which may include herbal supplements or other questionable items). In addition, orders are written and explained in simple language: i.e., “twice per day” instead of b.i.d. When patients visit their PCP after discharge, they are instructed to bring the color-coded bags so that the PCPs can verify the coherence of the orders. Clarity reports are filed for each physician, allowing a feedback mechanism to make sure that med rec is taking place.
• Open charting at Griffin Hospital in Derby, Conn., in affiliation with the principles of the nonprofit, patient-centered Planetree organization, supplies another means of double-checking the veracity of patients’ medication lists. It also allows for meaningful patient education and dialogue about treatment and discharge plans, says Dorothea Wild, MD, Griffin Hospital’s chief hospitalist.

Gretchen Henkel is a freelance writer based in California.

Because “med rec” is a responsibility shared by providers, patients, and families, it’s important to engage everyone in the process.

Although the patient is—and should be, if capable—the ultimate owner of the correct healthcare record, “We have a responsibility as healthcare providers to help them be successful,” says Blake Lesselroth, MD, assistant professor of medicine at Oregon Health Sciences University and director of the Portland Patient Safety Center of Inquiry at the Portland VA Medical Center. “We haven’t done that.”

Hospitals and healthcare systems use varied strategies for including and empowering patients in the med-rec process:

• The Joint Commission launched its “Speak Up” program (PDF), which gives patients tools to help avoid mistakes with their medications.
• Last year, Southern California Kaiser Permanente rolled out its “medicine in a bag” initiative, according to hospitalist David Wong, MD. Patients are instructed to bring all of their medications (in their respective containers) to the hospital when they are admitted. Then, as the med-rec process is completed, medications are placed in green (take these meds), red (stop these meds), and yellow bags (which may include herbal supplements or other questionable items). In addition, orders are written and explained in simple language: i.e., “twice per day” instead of b.i.d. When patients visit their PCP after discharge, they are instructed to bring the color-coded bags so that the PCPs can verify the coherence of the orders. Clarity reports are filed for each physician, allowing a feedback mechanism to make sure that med rec is taking place.
• Open charting at Griffin Hospital in Derby, Conn., in affiliation with the principles of the nonprofit, patient-centered Planetree organization, supplies another means of double-checking the veracity of patients’ medication lists. It also allows for meaningful patient education and dialogue about treatment and discharge plans, says Dorothea Wild, MD, Griffin Hospital’s chief hospitalist.

Gretchen Henkel is a freelance writer based in California.

Because “med rec” is a responsibility shared by providers, patients, and families, it’s important to engage everyone in the process.

Although the patient is—and should be, if capable—the ultimate owner of the correct healthcare record, “We have a responsibility as healthcare providers to help them be successful,” says Blake Lesselroth, MD, assistant professor of medicine at Oregon Health Sciences University and director of the Portland Patient Safety Center of Inquiry at the Portland VA Medical Center. “We haven’t done that.”

Hospitals and healthcare systems use varied strategies for including and empowering patients in the med-rec process:

• The Joint Commission launched its “Speak Up” program (PDF), which gives patients tools to help avoid mistakes with their medications.
• Last year, Southern California Kaiser Permanente rolled out its “medicine in a bag” initiative, according to hospitalist David Wong, MD. Patients are instructed to bring all of their medications (in their respective containers) to the hospital when they are admitted. Then, as the med-rec process is completed, medications are placed in green (take these meds), red (stop these meds), and yellow bags (which may include herbal supplements or other questionable items). In addition, orders are written and explained in simple language: i.e., “twice per day” instead of b.i.d. When patients visit their PCP after discharge, they are instructed to bring the color-coded bags so that the PCPs can verify the coherence of the orders. Clarity reports are filed for each physician, allowing a feedback mechanism to make sure that med rec is taking place.
• Open charting at Griffin Hospital in Derby, Conn., in affiliation with the principles of the nonprofit, patient-centered Planetree organization, supplies another means of double-checking the veracity of patients’ medication lists. It also allows for meaningful patient education and dialogue about treatment and discharge plans, says Dorothea Wild, MD, Griffin Hospital’s chief hospitalist.

Gretchen Henkel is a freelance writer based in California.

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When a patient is diagnosed with cancer, family members often assume responsibility for providing care. They are typically involved not only with the diagnostic and treatment phases of care but also across the care trajectory and into survivorship. These caregivers are a primary source of support to individuals with cancer. The purpose of this article is to present an overview of the challenges, needs, and roles of family caregivers over the course of the cancer treatment trajectory and to discuss what support the professionals can provide.

Click of the PDF icon at the top of this introduction to read the full article.

When a patient is diagnosed with cancer, family members often assume responsibility for providing care. They are typically involved not only with the diagnostic and treatment phases of care but also across the care trajectory and into survivorship. These caregivers are a primary source of support to individuals with cancer. The purpose of this article is to present an overview of the challenges, needs, and roles of family caregivers over the course of the cancer treatment trajectory and to discuss what support the professionals can provide.

Click of the PDF icon at the top of this introduction to read the full article.

When a patient is diagnosed with cancer, family members often assume responsibility for providing care. They are typically involved not only with the diagnostic and treatment phases of care but also across the care trajectory and into survivorship. These caregivers are a primary source of support to individuals with cancer. The purpose of this article is to present an overview of the challenges, needs, and roles of family caregivers over the course of the cancer treatment trajectory and to discuss what support the professionals can provide.

Click of the PDF icon at the top of this introduction to read the full article.

SAN DIEGO – Stretching out the delivery of rituximab significantly improved overall and event-free survival among older patients with poor-prognosis diffuse large B-cell lymphoma, German investigators reported.

Patients older than 60 years who had diffuse large B-cell lymphoma (DLBCL) were treated with the CHOP regimen and rituximab (Rituxan) on days 4 and 1 before CHOP and at increasing intervals thereafter, in the SMARTE-R-CHOP-14 trial.

Those with poor-prognosis disease had an overall survival rate of 80% at 37 months, compared with 67% for similar patients treated with CHOP and biweekly rituximab in an earlier trial (P = .034), reported Dr. Michael Pfreundschuh on behalf of his colleagues in the German High-Grade Non-Hodgkin's Lymphoma Study Group.

Event-free survival rates among poor-prognosis patients (defined as those with an International Prognostic Index [IPI] score higher than 2) were also significantly higher with the extended rituximab–dosing schedule, dubbed SMARTE-R-CHOP-14, at 67% vs. 54% for patients who received biweekly rituximab in the previous RICOVER-60 trial (P = .030).

"SMARTE-R-CHOP 14 has achieved by far the best results reported to date for elderly patients with poor prognosis," said Dr. Pfreundschuh of Saarland University in Homburg, Germany, at the annual meeting of the American Society of Hematology (ASH).

Giving rituximab every 3 weeks after 2 pre-CHOP doses maintains serum levels of rituximab over a longer period than when it is given every other week, he said.

Patients with good- or moderate-prognosis disease (defined as an IPI of 1 or 2) also had numerically better event-free and overall survival rates, compared with patients treated with biweekly rituximab, he noted, but the differences were not significant.

Although CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) given every 14 days (CHOP-14) had been shown to be superior to CHOP given every 21 days (CHOP-21), the same could not be said when rituximab was added (R-CHOP-14 vs. R-CHOP-21). Presentations at ASH in 2009 and at the American Society of Clinical Oncology annual meeting in 2011 suggested that biweekly rituximab dosing was suboptimal, Dr. Freundschuh said.

In the SMARTE-R-CHOP-14 study, Dr. Pfreundschuh and colleagues treated 190 patients with DLBCL with six cycles of CHOP-14. combined with eight cycles of rituximab 375 mg/m². The first three rituximab cycles were given in a dose-dense fashion on days 1 and 4 before CHOP, followed by infusions on days 10, 29, 57, 99, 155, and 239. Patients also received prophylaxis against infections with levofloxacin, acyclovir, and cotrimoxazole. One patient did not give informed consent for the trial, and was not included in the final analysis.

In the RICOVER-60 trial that was used for comparison, patients received six cycles of CHOP plus rituximab given on days 1, 15, 29, 43, 57, 71, 85, and 99. The baseline characteristics of patients were similar between the trials, except that significantly more patients in SMARTE-R-CHOP-14 had high-risk disease (P = .015).

Complete response rates overall were not significantly different (85% in SMARTE-R and 78% in RICOVER-60). Among patients with IPI scores less than 2, the respective rates were 90% and 84%, also not significantly different. Among patients with an IPI greater than 2, however, the complete response rate in SMARTE-R-CHOP-14 was 81%, compared with 68% in RICOVER-60 (P = .035).

Overall survival did not differ significantly between the trials, at 84% in SMARTE-R and 78% in RICOVER. When patients stratified by risk were considered, there were no between-trial differences for low-risk patients.

Overall event-free survival was 71% at 37 months’ median follow-up in SMARTE-R, and 66% at 34 months in RICOVER; this difference was not significant, nor was the difference between the trials among patients with low-risk disease.

"The pharmacokinetics of eight biweekly applications of rituximab are adequate for elderly patients with good prognosis, meaning patients with IP1 1 or 2, or low tumor burden diffuse large B-cell lymphoma, but not for higher tumor loads," Dr. Pfreundschuh said.

The investigators are exploring the SMARTE-R treatment strategy in a prospective trial, labeled "OPTIMAL Greater Than 60."

The trial was supported by Deutsche Krebshilfe and Roche. Dr. Pfreundschuh disclosed serving on a Roche board of directors or advisory committee, and receiving research funding from that company and from Amgen.

SAN DIEGO – Stretching out the delivery of rituximab significantly improved overall and event-free survival among older patients with poor-prognosis diffuse large B-cell lymphoma, German investigators reported.

Patients older than 60 years who had diffuse large B-cell lymphoma (DLBCL) were treated with the CHOP regimen and rituximab (Rituxan) on days 4 and 1 before CHOP and at increasing intervals thereafter, in the SMARTE-R-CHOP-14 trial.

Those with poor-prognosis disease had an overall survival rate of 80% at 37 months, compared with 67% for similar patients treated with CHOP and biweekly rituximab in an earlier trial (P = .034), reported Dr. Michael Pfreundschuh on behalf of his colleagues in the German High-Grade Non-Hodgkin's Lymphoma Study Group.

Event-free survival rates among poor-prognosis patients (defined as those with an International Prognostic Index [IPI] score higher than 2) were also significantly higher with the extended rituximab–dosing schedule, dubbed SMARTE-R-CHOP-14, at 67% vs. 54% for patients who received biweekly rituximab in the previous RICOVER-60 trial (P = .030).

"SMARTE-R-CHOP 14 has achieved by far the best results reported to date for elderly patients with poor prognosis," said Dr. Pfreundschuh of Saarland University in Homburg, Germany, at the annual meeting of the American Society of Hematology (ASH).

Giving rituximab every 3 weeks after 2 pre-CHOP doses maintains serum levels of rituximab over a longer period than when it is given every other week, he said.

Patients with good- or moderate-prognosis disease (defined as an IPI of 1 or 2) also had numerically better event-free and overall survival rates, compared with patients treated with biweekly rituximab, he noted, but the differences were not significant.

Although CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) given every 14 days (CHOP-14) had been shown to be superior to CHOP given every 21 days (CHOP-21), the same could not be said when rituximab was added (R-CHOP-14 vs. R-CHOP-21). Presentations at ASH in 2009 and at the American Society of Clinical Oncology annual meeting in 2011 suggested that biweekly rituximab dosing was suboptimal, Dr. Freundschuh said.

In the SMARTE-R-CHOP-14 study, Dr. Pfreundschuh and colleagues treated 190 patients with DLBCL with six cycles of CHOP-14. combined with eight cycles of rituximab 375 mg/m². The first three rituximab cycles were given in a dose-dense fashion on days 1 and 4 before CHOP, followed by infusions on days 10, 29, 57, 99, 155, and 239. Patients also received prophylaxis against infections with levofloxacin, acyclovir, and cotrimoxazole. One patient did not give informed consent for the trial, and was not included in the final analysis.

In the RICOVER-60 trial that was used for comparison, patients received six cycles of CHOP plus rituximab given on days 1, 15, 29, 43, 57, 71, 85, and 99. The baseline characteristics of patients were similar between the trials, except that significantly more patients in SMARTE-R-CHOP-14 had high-risk disease (P = .015).

Complete response rates overall were not significantly different (85% in SMARTE-R and 78% in RICOVER-60). Among patients with IPI scores less than 2, the respective rates were 90% and 84%, also not significantly different. Among patients with an IPI greater than 2, however, the complete response rate in SMARTE-R-CHOP-14 was 81%, compared with 68% in RICOVER-60 (P = .035).

Overall survival did not differ significantly between the trials, at 84% in SMARTE-R and 78% in RICOVER. When patients stratified by risk were considered, there were no between-trial differences for low-risk patients.

Overall event-free survival was 71% at 37 months’ median follow-up in SMARTE-R, and 66% at 34 months in RICOVER; this difference was not significant, nor was the difference between the trials among patients with low-risk disease.

"The pharmacokinetics of eight biweekly applications of rituximab are adequate for elderly patients with good prognosis, meaning patients with IP1 1 or 2, or low tumor burden diffuse large B-cell lymphoma, but not for higher tumor loads," Dr. Pfreundschuh said.

The investigators are exploring the SMARTE-R treatment strategy in a prospective trial, labeled "OPTIMAL Greater Than 60."

The trial was supported by Deutsche Krebshilfe and Roche. Dr. Pfreundschuh disclosed serving on a Roche board of directors or advisory committee, and receiving research funding from that company and from Amgen.

SAN DIEGO – Stretching out the delivery of rituximab significantly improved overall and event-free survival among older patients with poor-prognosis diffuse large B-cell lymphoma, German investigators reported.

Patients older than 60 years who had diffuse large B-cell lymphoma (DLBCL) were treated with the CHOP regimen and rituximab (Rituxan) on days 4 and 1 before CHOP and at increasing intervals thereafter, in the SMARTE-R-CHOP-14 trial.

Those with poor-prognosis disease had an overall survival rate of 80% at 37 months, compared with 67% for similar patients treated with CHOP and biweekly rituximab in an earlier trial (P = .034), reported Dr. Michael Pfreundschuh on behalf of his colleagues in the German High-Grade Non-Hodgkin's Lymphoma Study Group.

Event-free survival rates among poor-prognosis patients (defined as those with an International Prognostic Index [IPI] score higher than 2) were also significantly higher with the extended rituximab–dosing schedule, dubbed SMARTE-R-CHOP-14, at 67% vs. 54% for patients who received biweekly rituximab in the previous RICOVER-60 trial (P = .030).

"SMARTE-R-CHOP 14 has achieved by far the best results reported to date for elderly patients with poor prognosis," said Dr. Pfreundschuh of Saarland University in Homburg, Germany, at the annual meeting of the American Society of Hematology (ASH).

Giving rituximab every 3 weeks after 2 pre-CHOP doses maintains serum levels of rituximab over a longer period than when it is given every other week, he said.

Patients with good- or moderate-prognosis disease (defined as an IPI of 1 or 2) also had numerically better event-free and overall survival rates, compared with patients treated with biweekly rituximab, he noted, but the differences were not significant.

Although CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) given every 14 days (CHOP-14) had been shown to be superior to CHOP given every 21 days (CHOP-21), the same could not be said when rituximab was added (R-CHOP-14 vs. R-CHOP-21). Presentations at ASH in 2009 and at the American Society of Clinical Oncology annual meeting in 2011 suggested that biweekly rituximab dosing was suboptimal, Dr. Freundschuh said.

In the SMARTE-R-CHOP-14 study, Dr. Pfreundschuh and colleagues treated 190 patients with DLBCL with six cycles of CHOP-14. combined with eight cycles of rituximab 375 mg/m². The first three rituximab cycles were given in a dose-dense fashion on days 1 and 4 before CHOP, followed by infusions on days 10, 29, 57, 99, 155, and 239. Patients also received prophylaxis against infections with levofloxacin, acyclovir, and cotrimoxazole. One patient did not give informed consent for the trial, and was not included in the final analysis.

In the RICOVER-60 trial that was used for comparison, patients received six cycles of CHOP plus rituximab given on days 1, 15, 29, 43, 57, 71, 85, and 99. The baseline characteristics of patients were similar between the trials, except that significantly more patients in SMARTE-R-CHOP-14 had high-risk disease (P = .015).

Complete response rates overall were not significantly different (85% in SMARTE-R and 78% in RICOVER-60). Among patients with IPI scores less than 2, the respective rates were 90% and 84%, also not significantly different. Among patients with an IPI greater than 2, however, the complete response rate in SMARTE-R-CHOP-14 was 81%, compared with 68% in RICOVER-60 (P = .035).

Overall survival did not differ significantly between the trials, at 84% in SMARTE-R and 78% in RICOVER. When patients stratified by risk were considered, there were no between-trial differences for low-risk patients.

Overall event-free survival was 71% at 37 months’ median follow-up in SMARTE-R, and 66% at 34 months in RICOVER; this difference was not significant, nor was the difference between the trials among patients with low-risk disease.

"The pharmacokinetics of eight biweekly applications of rituximab are adequate for elderly patients with good prognosis, meaning patients with IP1 1 or 2, or low tumor burden diffuse large B-cell lymphoma, but not for higher tumor loads," Dr. Pfreundschuh said.

The investigators are exploring the SMARTE-R treatment strategy in a prospective trial, labeled "OPTIMAL Greater Than 60."

The trial was supported by Deutsche Krebshilfe and Roche. Dr. Pfreundschuh disclosed serving on a Roche board of directors or advisory committee, and receiving research funding from that company and from Amgen.