Recognition

The following is based on an actual case that occurred a long time ago in a galaxy far, far away.

A 65-year-old man arrived in the emergency department by ambulance after being found unresponsive. His respiratory rate was 40/minute, heart rate was 170/minute, and temperature was 102.2°. He did not respond to Narcan or an ampule of 50% dextrose. Blood sugar was 600 mg/dL. The diagnosis of diabetic ketoacidosis was made. IV fluids and an insulin drip were given. After some hydration he became more alert and complained of abdominal pain. On examination, his abdomen was tender to palpation. Four hours after arrival, a surgical consultant was called and diagnosed an incarcerated inguinal hernia. Before the patient could be taken to surgery, he suffered a cardiac arrest and could not be resuscitated. Review of the case revealed that although blood cultures were drawn and were eventually positive, antibiotics had not been ordered.

What happened? The possibility that this patient was septic never occurred to the doctors managing the case. I am sure that if a scenario like this appeared on a test, those doctors would have immediately chosen the right antibiotics. Some doctors are "book smart" but can't deal with a real live patient.

Do more hospital resources equal better care?

For surgical patients, the answer is "Yes."

A recent study from England found that mortality rates for patients admitted with high-risk general surgery diagnoses were significantly lower in National Health Service Trust hospitals that used more CT scans and ultrasounds and had more ICU beds.

During the first decade of this century, nearly 368,000 patients were admitted as emergencies to English hospitals with surgical diagnoses carrying mortality rates in excess of 5%.

The diseases were bowel obstruction, liver/biliary conditions, hernias with obstruction or gangrene, peritonitis, gastrointestinal ulcers, perforated diverticulitis, bowel ischemia and miscellaneous diagnoses.

The 30-day risk-adjusted in-hospital mortality rate for the eight illnesses was 15.5% with a range of 9.2% in low-mortality hospital trusts (LMHTs) to 18.2% in high mortality hospital trusts (HMHTs). An operation was performed in 37.4% of patients, and 14.9% were readmitted within 28 days.

Three factors significantly differentiated LMHTs from HMHTs:

LMHTs had 20 ICU beds per 1000 beds vs. 14 for HMHTs, p = 0.017.

LMHTs performed 24.6 CT scans per bed per year vs. 17.2 for HMHTs, p < 0.001.

LMHTs performed 42.5 ultrasounds per bed per year vs. 30 for HMHTs, p < 0.001.

Some limitations of the study included the fact that it was based on administrative data. There was no way to determine if the increased use of imaging or availability of ICU beds had a direct effect on patients admitted with emergency surgical diagnoses. Also, variables such as delays in surgery or competence of surgeons could not be investigated.

Despite its limitations, this study is provocative.

No doubt the HMHT hospitals, which have fewer ICU beds and perform fewer imaging studies, are not as expensive.

But the study suggests that if you have the misfortune to arrive at an HMHT hospital with one of the surgical diagnoses listed above, you may have twice the chance of dying than if you had gone to an LMHT hospital that utilizes more resources.

This study is supported by a Viewpoint article in October's JAMA Surgery which looked at two studies of postoperative care in the UK and Europe. In both papers, many seriously ill postoperative patients did not receive appropriate levels of critical care. "Among patients who died during hospitalization after major surgical procedures in the United Kingdom in 2001, approximately 8.5% were admitted to an ICU at some point in their hospital stay. During the same period in the United States, this figure was 7 times greater, 61%."

In the European study, only 5% of surgery patients had planned admissions to intensive care, and 75% of those who died postop did not spend any time in an ICU.

The authors added, "in efforts to achieve good surgical outcomes, there really may be no free lunch: tradeoffs between cost and quality are inherent to the contemporary delivery of intraoperative and postoperative care."

What do you think?

Journals, Open Access Journals and More Journals

I recently received an email inviting me to join the editorial board of a relatively new online, open access journal. I am not aware of how I was chosen for this honor. I either am or have been a manuscript peer reviewer for five different journals and currently serve as an associate editor of one of them. But that information is not widely known. I have a decent bibliography, much of which is relevant to the journal’s subject matter. Maybe that’s it.

Manuscript peer reviewers and associate editors do not receive compensation for their work. Most of us view it as pro bono work for the benefit of advancing science and it is somewhat career-enhancing to be involved in the editorial process. One also can learn a lot about how journals deal with manuscripts that are submitted. This results in one becoming a better writer.

The email had a link to a list of the members of the editorial board. Of some 30, it contained only one name that I had heard of in the field. The website said the journal has an impact factor of 1.5. I could not verify that claim.

In case you aren’t familiar with open access journals, they generally do not charge the reader for a subscription or a fee to view some or all articles. Instead the authors pay an “article processing charge” which can be substantial.. A comparison of article processing charges lists fees up to $5000.00.

I am at the stage in my career where doing extra work for nothing to beef up my curriculum vitae is no longer a need. In reply to the email offering me a position of the editorial board of the open access journal, I asked if there was going to be any payment to the members of said board, who are the people doing the actual work of peer reviewing and re-reviewing manuscripts. I was told that no reimbursement would be possible.

Let’s say that an open access journal publishes 40 articles per month at $2500.00 per article. That’s $100,000.00 per issue times 12 issues or $1.2M per year. Not a bad gross income when one realizes that except for copy editing the papers and posting the finished product on the journal’s website, the intellectual work is being done by editorial board members and manuscript reviewers for free.

One of the largest open access publishers is BioMed Central [BMC]. I am not sure whether it pays any of its editorial board members or manuscript reviewers. However, BMC publishes 221 scientific journals, some of which charge the reader for accessing certain types of research. You can do your own math and see that this is big business. 

And here is another question. How many journals are needed? For example, the Thomson-Reuters Science Citation Index Expanded - Critical Care Medicine - Journal List shows 23 journals primarily devoted to the rather narrow field of critical care. This does not include other journals like Chest and Anesthesiology, which have sections on critical care. Two new critical care journals have appeared, TheScientificWorldJOURNAL [Critical Care] and Annals of Intensive Care.

Who has the time or interest to read 25 journals? What is the quality of the articles in all these journals? Does anyone read this stuff? Does anyone really care?

Less is more. Conventional wisdom challenged in two NEJM articles

Classical views on fluid resuscitation and nutrition in critically ill patients were questioned in two papers published today in the New England Journal of Medicine.

A large study involving febrile, under-perfused children in Africa reveals that those aggressively resuscitated with fluid boluses of either saline or albumin had higher mortality rates than a control group who were not given boluses of fluid. The study was stopped earlier than planned when the research group’s data and safety monitoring committee performed an interim analysis. This paper adds to a growing body of research that shows that large-volume fluid resuscitation may be harmful in many situations.

A second article demonstrated that in some 4600 critically ill patients given enteral nutrition, late (day 8 of ICU admission) initiation of parenteral nutrition to supplement the enteral nutrition and achieve caloric goals leads to fewer complications and faster discharge from the ICU than patients whose parenteral nutrition was started within 48 hours of their ICU stay.

The papers are accompanied by editorials (here and here) that provide perspective and as usual caution against overly interpreting the results.

Although the messages seem quite clear (especially regarding large-volume fluid resuscitation), clinicians should read both papers and decide for themselves.

Alarms! Sounding the Alarm on Alarms, Finally

“Patient alarms often unheard, unheeded” states a recent headline in the Boston Globe. Now the Joint Commission and the FDA are going to target “alarm fatigue” as a patient safety priority. Apparently it is not a very high priority as the article describing the effort states that the two organizations will be meeting “over the next few months” to “pinpoint a strategy.”

My question is, where has everyone been? This issue has been apparent for years to anyone who has ever worked in an intensive care unit. Walk into any ICU and within 30 seconds, you will hear an alarm sound its annoying bleat and see the staff going about their business without a second thought.

As far back as the early 1990s, studies documented the issues. There are too many alarms. In 1994, researchers from Ohio published a study in which they played some 33 different common alarm tones for 100 ICU staff members. Only 50% of them were able to identify the source of each alarm. The authors concluded that there were too many alarms for even experienced staff to identify and proposed that alarms should be used for only critical problems.

Another 1994 study from a pediatric ICU observed alarm activity over a week’s time. They noted that of 2,176 alarm soundings, 68% were false, 26.5% were induced by staff dealing with patients and only 5.5% were actually significant.

An interesting study performed on college students in 1995 showed that people respond to alarms on the basis of their expectations. In other words, if an alarm is known to usually be false, the individual is less likely to respond to it. Obviously, if 95% of alarms in an ICU are false, the staff will be conditioned to ignore them.

There have been many other papers on the subject documenting the above as well as the stress on the staff that the constant level of noise produces.

In 2011, the problem is even worse as more and more devices have related alarms. For example, the push to prevent patient falls has prompted the invention of the bed alarm. Some of these alarms are so sensitive that the mere touching of the bed by staff triggers the alarm.

The solution to the problem of alarm fatigue is not simple. Every new device seems to come with its own random noise and sound level. A concerted effort by device manufacturers, regulatory agencies and hospitals is needed. My suggestion is to 1) scrap all current alarms and develop standardized tones for a select few important events and 2) improve the sensitivity of triggers to reduce the false alarm rate. Good luck.