Jun 2, 2017

Bundle up

The story

In residency, you don't make the rules, and it's hard to know who does. So what happens when a state government turns clinical guidelines for sepsis management into law? 

The background

Residency and government are very much entangled: Uncle Sam supports most resident salaries through Medicare, but places legal restrictions on the ability of residents to negotiate with their employers. Yet for the extent of involvement between the two parties, it's not often that government dictates how residents and hospitals care for medicine patients. In 2013 New York State (NYS) mandated that hospitals use evidence-based protocols for sepsis treatment and report clinical outcomes to the state.

The bundle

Based largely on 2012's Surviving Sepsis Guidelines, all NYS protocols included 3 and 6-hour bundles focused on early recognition and treatment of sepsis. The 3-hour bundle included blood cultures, serum lactate level, and broad-spectrum antibiotics. The 6-hour bundle included IV fluid boluses (30 mL / kg) in patients with hypotension or elevated lactate, vasopressors for refractory hypotension, and a second lactate level within 6 hours of protocol initiation.

The results

Between 2014 - 2016, bundle compliance increased from 42% to 55%, while mortality from sepsis fell from 30% to 25%. A retrospective review of data from 50,000 patients at 149 hospitals in New York found that delays in recognition and treatment, including failure to promptly complete the 3-hour sepsis bundle and administer broad-spectrum antibiotics, were associated with higher in-hospital mortality among patients presenting to the emergency department with severe sepsis and septic shock. Mortality increased by 4% for each hour that bundle completion was delayed.

The takeaway

Legal mandates are a big change in sepsis treatment, but the retrospective results are promising. Since sepsis mortality is on the decline nationwide, prospective or randomized data may help sort out how the New York State mandate affects care.

Say it on rounds

When a shot of whole milk turns coffee into breakfast

The right supplement is crucial. A 120-patient RCT found that home oxygen therapy combined with non-invasive ventilation (NIV) decreased risk of readmission or death by 20% at 1 year compared to home oxygen alone in patients discharged after acute COPD exacerbation. Prior studies have not always shown a benefit for NIV in COPD, and experts think the study's positive results stem from high vent pressures and enrollment of patients with severe carbon dioxide retention.

When you eat a Big Mac after a month in the CCU

Feels weird, right? An analysis of 500,000 participants in the NIH-AARP Diet and Health Study found an association between red meat consumption and all-cause mortality as well as disease-specific mortality including cancer, heart disease, and diabetes. Those who opted for chicken fared better: the highest quintile of white meat eaters had a 25% reduction in all-cause mortality relative to the lowest quintile. Despite its 'other white meat' marketing status, pork was grouped with red meat.

When your patient requests a non-teaching service

Be our guest. But be warned that an observational study of 21 million Medicare beneficiaries found that admission to a teaching hospital was associated with lower overall 30-day mortality than admission to a non-teaching hospital. The mortality rates for 11 of 15 individual common medical conditions were also lower at teaching hospitals. What's driving the data remains unclear, but the results fall in line with 90's era studies that found improved outcomes at academic medical centers.

Brush up


Misfold your clothes and everyone thinks you’re an all-star intern who works too hard, but misfold your proteins and you're in trouble. Cardiac amyloidosis arises from insoluble protein deposits in cardiac myocytes. Look for heart failure with preserved ejection fraction and other features of restrictive cardiomyopathy, though the disease is often mistaken for hypertensive cardiomyopathy or ischemic heart disease. Low-voltage is a key finding on EKG. Treat with diuretics, but avoid beta blockers as they can cause symptomatic decline.

What's the evidence

For PYP scanning in transthyretin (TTR) cardiac amyloidosis? Invasive biopsy is traditionally the gold standard for diagnosis of the two most common types of amyloidosis: TTR amyloid and amyloid light-chain (AL). A 2013 study of 45 patients with biopsy-proven amyloid found that nuclear scintigraphy with pyrophosphate (PYP) was 97% sensitive and 100% specific for TTR amyloid diagnosis. The scan can spare biopsies and give clinicians information about the extent and distribution of disease.

What your mad scientist friends are talking about

Your dreams of replacing your least favorite attending with one you like better are less far-fetched than you think: the first human head transplant is purportedly on schedule for later this year. This video has more.

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