Medicine of the Future in America

Category Archives: Pulmonary function - Part 2

Preventing Ventilator-Associated Pneumonia in Adults

Preventing Ventilator-Associated Pneumonia in AdultsVentilator-associated pneumonia (VAP) is common and associated with high morbidity, mortality, and health-care costs, estimated to be $40,000/case. VAP has a cumulative incidence of 10 to 25% and accounts for approximately 25% of all ICU infections and > 50% of the antibiotics prescribed in ICU, making it a primary focus for risk-reduction strategies. Crude mortality rates for VAP may be as high as 20 to 70% and are generally highest in medical ICU patients and those with bacteremia or pneumonia due to multidrug-resistant (MDR) pathogens, such as Pseudomonas aeruginosa or Acinetobacter species, and methicillin-resistant Staphylococcus aureus (MRSA).
Due to the limitations on space and the number of citations for this review, highlights from selected guidelines and publications on VAP prevention in adults, primarily published after January 1, 2003, were included. Emphasis was placed on new concepts, controversies, and barriers to implementing beneficial, cost-effective programs aimed at reducing VAP and improving patient outcomes.
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Antibiotic Timing and Diagnostic Uncertainty in Medicare Patients With Pneumonia: Recommendation

This may have been in part due to our low sample size or the presence of other factors such as ED patient volume and staff/patient ratios that could affect the timing of the administration of antibiotics. This result could also suggest that the reviewers’ finding of diagnostic uncertainty was not relevant to what actually occurred when these patients were treated. However, this seems unlikely, given the lower frequency of physical examination and chest radiograph findings and frequent evidence of diagnostic uncertainty in the medical records of these patients. A more likely interpretation is that the timing of antibiotic administration performance measure prompts antibiotic treatment as soon as respiratory symptoms are elicited, often before a diagnosis of pneumonia is confirmed.
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Antibiotic Timing and Diagnostic Uncertainty in Medicare Patients With Pneumonia: Conclusion

Antibiotic Timing and Diagnostic Uncertainty in Medicare Patients With Pneumonia: ConclusionIt may be inappropriate to expect hospitals to deliver antibiotics to all pneumonia patients within 4 h of presentation, as doing so would necessitate antibiotics being administered to many patients in whom the diagnosis of pneumonia would still be in doubt.
There is already concern that a target of 100% leads to inappropriate antibiotic use, which could decrease the yield of subsequent diagnostic tests in some patients and could stimulate the development of antibiotic resistance. Perhaps most importantly, efforts to achieve a target of 100% might result in the diversion of limited resources from other patients who might be more in need of prompt care. http://canadianhealthcaremallinc.com/

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Antibiotic Timing and Diagnostic Uncertainty in Medicare Patients With Pneumonia: Discussion

Acute mental status changes were almost twice as common in patients with diagnostic uncertainty, but this difference did not reach statistical significance (p = 0.12). The lack of rales, oxygen desaturation, or a chest radiograph suggesting pneumonia were all significantly more common in patients with diagnostic uncertainty. It is noteworthy that among these 78 patients, all with a hospital discharge diagnosis of pneumonia, 19 (24%) did not have a chest radiograph finding that was suggestive of pneumonia. Two of these patients also had a chest CT scan that did not demonstrate an infiltrate. Twenty-one of the patients (27%) who had been admitted to the hospital through the ED received initial antibiotic therapy > 4 h after presentation. Thirty-eight percent of these patients had abdominal symptoms, while only 11% of those without delayed antibiotic administration had abdominal symptoms (p = 0.005). None of the other clinical factors listed in Table 1 were associated with the receipt of antibiotics after 4 h. Table 2 demonstrates the association between the mean time to antibiotic administration and patient characteristics. A significantly longer time until the receipt of antibiotics was associated with hospital admission from a facility other than home. Patients with abdominal symptoms received antibiotics a mean of 2 h and 23 min later than patients without such symptoms, but this difference fell short of achieving statistical significance (p = 0.07). storehealthmall.eu

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Antibiotic Timing and Diagnostic Uncertainty in Medicare Patients With Pneumonia: Research

Antibiotic Timing and Diagnostic Uncertainty in Medicare Patients With Pneumonia: ResearchOften, while pneumonia was listed by the ED physician as one of the final diagnoses, heart failure or exacerbation of COPD was also mentioned, and frequently was listed above pneumonia. In six of these cases, the reviewers felt that antibiotic treatment would have been appropriate for any alternative diagnosis (usually an acute exacerbation of COPD), but it would have been appropriate for the ED physician to defer the antibiotic choice to the admitting physician.
Among these 19 cases, there was initial interobserver disagreement for 14 cases (74%). There were three specific reasons for initial disagreement. In two cases, a reviewer overlooked a key piece of the data in the record, and once this was pointed out he changed his opinion. More often, the differences were due to diagnostic uncertainty.

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Antibiotic Timing and Diagnostic Uncertainty in Medicare Patients With Pneumonia: Results

The report of pneumonia, infiltrates, consolidation, opacity, or a similar synonym was accepted as representing pneumonia unless the conclusion made no mention of pneumonia and contained an alternate diagnosis. Summary statistics and univariate tests of association were performed. The x2 test was used for categoric variables, and the Student t test was used for continuous variables. Statistical significance was accepted at p = 0.05. Analyses were conducted using a statistical software package (SAS, version 8.0; SAS Institute; Cary, NC). As a component of the Centers for Medicare & Medicaid Services quality-improvement activities, this study was exempt from institutional review board approval.
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Antibiotic Timing and Diagnostic Uncertainty in Medicare Patients With Pneumonia: Methods

Antibiotic Timing and Diagnostic Uncertainty in Medicare Patients With Pneumonia: MethodsEach chart was reviewed independently by the reviewers, who were asked one key question, as follows: was there a potential reason for a delay of antibiotic administration other than quality of care? It was anticipated that such cases in which the answer was “yes” would generally be due to diagnostic uncertainty such that the diagnosis of pneumonia would likely not have been made soon enough to deliver antibiotics within 4 h. Inherent in this designation was acceptance of the premise that in the absence of diagnostic uncertainty or an unusual patient-related circumstance that prevented the timely delivery of antibiotics, a delay in antibiotic treatment represented a lapse in quality. canadian neighbor pharmacy online

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Antibiotic Timing and Diagnostic Uncertainty in Medicare Patients With Pneumonia: Materials

Randomly selected charts of Medicare patients with a hospital discharge diagnosis of pneumonia fulfilling the criteria for inclusion in Medicare pneumonia reporting were made available to the investigators. The criteria for inclusion in the Medicare reporting have been described in detail previously. A key inclusion criterion for the antibiotic timing measure was that pneumonia had to be among the diagnoses being considered at the time of hospital admission. A confirmatory chest radiograph was not required. Patients with documented antibiotic treatment within 24 h prior to presentation were excluded. A sample size of 80 to 100 patients was planned, due to investigator time and resource constraints, as this was an unfunded study. With this sample size, an analysis prior to commencing the study revealed an acceptable predicted 95% confidence interval based on an anticipated prevalence of diagnostic uncertainty of at least 15%. read

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Antibiotic Timing and Diagnostic Uncertainty in Medicare Patients With Pneumonia

Antibiotic Timing and Diagnostic Uncertainty in Medicare Patients With PneumoniaThe Centers for Medicare & Medicaid Services conducts a multipronged program to encourage improvements in quality of care for Medicare beneficiaries. The timing of antibiotic therapy for patients who have been admitted to the hospital with pneumonia has been an audited performance measure for pneumonia for many years, as reports have demonstrated improved outcomes among patients who received antibiotics within 4 h of presentation. With the recent trend of using this and other performance measures as the basis for public reporting and pay-for-performance programs, there is increasing pressure for hospitals and physicians to drive their performance rates as high as possible. The only way to ensure not being outperformed by another institution in the competition for reimbursement (in many pay-for-performance programs) or for patients (in the case of publicly reported quality measures) is to achieve 100% adherence. there

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Delayed Administration of Antibiotics and Atypical Presentation in Community-Acquired Pneumonia: Conclusion

Delayed Administration of Antibiotics and Atypical Presentation in Community-Acquired Pneumonia: ConclusionIf TFAD is used as a quality-of-care marker, it cannot be compared across institutions without good information on the proportion of patients who present with an altered mental state or an otherwise atypical presentation. Although captured by the PSI, this information is lost when only the total score is factored into the analysis.
The Medicare database studies were also limited by the fact that data were collected retrospectively and that key data points were not always available. As our study was prospective and patients were seen by an investigator within 24 h of presentation, we can be much more confident of the diagnosis of pneumonia and the relevant features of the clinical presentation. This may be particularly pertinent with respect to the recognition and documentation of an altered mental state in elderly patients. further

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