Hospital Consult - June 2016

Critical Access Hospitals As Good, Or Better, for Common Surgical Procedures

ANN ARBOR, MI – Bigger isn’t always better, according to a new study which finds that critical access hospitals aren’t always just waystations to higher-quality care in larger institutions.

In fact, a study published in the Journal of the American Medical Association finds that rural hospitals can be safer and less expensive for some common surgical procedures.

The small-town facilities are the closest acute care option for millions of Americans living in rural areas. University of Michigan-led researchers found that, in many cases, relatively healthy patients might do better having surgery close to home than traveling to a hospital in a metropolitan area.

For the study, data was analyzed from 1.6 million hospital stays for four common procedures — gallbladder removal, colon surgery, hernia repair and appendectomy — with Medicare patients having surgery at 828 critical access hospitals compared to those treated at more than 3,600 larger hospitals.

Results indicate that the risk of dying within 30 days was the same whether a patient had surgery at a critical access hospital or a larger hospital, while the risk of suffering a major complication after surgery, such as a heart attack, pneumonia or kidney damage, actually was lower at critical access hospitals.

In terms of expense, patients treated at a critical access hospital cost the Medicare system nearly $1,400 less than patients who had surgery at a larger hospital, after differences in patient risk were considered.

The study also suggests that surgeons at critical access hospitals are appropriately selecting healthier patients who are likely to do well in a small rural setting, while triaging more complex patients to larger centers.

Even after the researchers corrected for differences in preoperative health, the critical access hospitals posted equal or better outcomes.

Background information in the article points out that hundreds of critical access hospitals are in danger of closing, despite current Medicare policy to pay more than the actual cost of care to help them stay financially viable.

"From a surgical standpoint, these hospitals appear to be doing exactly what we would want them to be doing: common operations on appropriately selected patients who are safe to stay locally for their care," explained lead author Andrew Ibrahim, MD, of the University of Michigan.

"The goal of the rural surgeon is best care nearest home,” added co-author Tyler Hughes, MD, of the critical access McPherson (KS) Hospital. “Data to assure that the care in rural centers is both safe and cost effective is critical in the decisions the profession faces in providing care to the 20% of the U.S. population living in truly rural environments. This study gives credence to what rural surgeons long suspected: that well-done rural surgery is safe and cost effective."

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Early Diabetes Detection Using HbA1c Testing in Hospitalized Patients

ATHENS, OH – Because of underuse of glycated hemoglobin testing, hospitals could be missing an opportunity for early diabetes detection among inpatients, according to a new study.

A retrospective review of medical records, published recently in the Journal of the American Osteopathic Association, found the HbA1c test can be used to detect hidden disease among hospital patients with hyperglycemia, even if the immediate cause is assumed to be hospital-administered medications or treatments.

A study team led by researchers from Ohio University Heritage College of Osteopathic Medicine retrospectively reviewed the medical records of 348 patients with hyperglycemia at a rural community teaching hospital in the Midwest. Of those patients, 50 had no known history of diabetes and 31 of them were given an HbA1c test, which measures the average blood glucose level over the previous eight to 12 weeks.

Testing results indicated that 58% had results consistent with diagnoses of diabetes, and another 19% fell in the range of prediabetes.

"In the hospital, we often find hyperglycemia when we're treating other illnesses, like sepsis or a heart attack. This study found that patients with no known history of diabetes whose HbA1c level was measured were five times more likely to leave the hospital with a diagnosis of new-onset diabetes," explained co-author Jay H. Shubrook, DO, of the College of Osteopathic Medicine at Touro University in Vallejo, CA.

Shubrook added that, “it's easy to make a case for hospital protocols to trigger an HbA1C test when hyperglycemia is detected to distinguish between transient hyperglycemia and chronic disease."

In this review, 55% of the tested patients had a discharge diagnosis that included diabetes, while 11% of the patients who had hyperglycemia in the hospital but no known history of diabetes (NKHD), nor the HbA1c test, left the hospital with that diagnosis.

“Hospitalized patients with NKHD and hyperglycemia are more likely to receive an appropriate diagnosis if HbA1c is measured,” study authors concluded. “Failing to fully use HbA1c tests in the inpatient setting constitutes a missed opportunity to distinguish transient hyperglycemia from chronic disease. The HbA1c level can elucidate the course of dysglycemia and trigger mechanisms for timely intervention.”

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Acoustical Presentation Urges Rethinking of Alarm Use in Hospitals

SALT LAKE CITY – Clinical alarm errors occur in U.S. hospitals more than 8 million times a day, with 90% of clinical alarms resulting in no action.

No wonder that hospital alarms are currently ranked as the "top medical technology hazard" within the United States, according to a session at the recent Acoustical Society of America's Spring 2016 Meeting.

A presentation by consultant Ilene Busch-Vishniac reports that the 480,000 patients in U.S. hospitals each generate an average of about 135 clinical alarms per day. Errors occur when alarms either fail to sound or go off but receive no response, according to the model, which was based on several recent studies of hospital alarms.

"In each case, alarms reflect a medically urgent situation or they don't," Busch-Vishniac explained. "For each situation, the response is either appropriate or inappropriate. This means there are eight possible scenarios associated with alarms, so we can estimate how often each occurs and how often errors occur."

In current studies, "the fraction of alarm errors reported as adversely affecting patients is extremely low," she added. "But alarms often don't serve the purpose for which they're intended: to alert medical staff to urgent situations. Instead, alarms go off all the time and rarely indicate truly urgent situations. And while the focus has been on ensuring that the hospital staff responds to all alarms, studies show that it's more common for alarm errors to occur because alarms that should sound fail to do so. This means that responding to all alarms won't eliminate most alarm errors."

While some research has suggested that hospital alarms negatively affect patient recovery, she said insufficient data is available at this time to really answer the question.

"Our work suggests that it's time to rethink alarm strategies entirely, with a goal of reducing the number of alarms to those that truly reflect urgent situations while balancing the need to alert staff with the need to establish quieter hospital environments," she added.

The study notes that data on the effects of alarm errors indicate about 200 related deaths per year and fewer than 500 adverse effects per year.

“A compelling conclusion from this data is that clinical alarms in hospital are very inefficient and ineffective tools for monitoring medical emergencies,” Busch-Vishniac said. “Much attention has been dedicated to alarms recently, with the general goal of improving response to alarms in order to ensure no medical emergency is missed. While this work is of immediate use and is vitally important to the operation of the modern hospital, it focuses on minor changes to the existing systems rather than on trying to design the optimum system for the future.”

She suggested comparing outcomes of patients when alarms sound within their area vs. when alarms are intentionally muted and sent to staff via pagers or cell phones, adding, "This will help to establish whether alarms potentially harm patients, as well as save lives.”

Other areas requiring exploration, she said, include when alarms should sound, which sounds should be used, and ways to make alarm systems more intelligent by combining information from multiple medical devices.

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Emergency General Surgery Has Greatest Risks, Highest Costs

BOSTON – Emergency general surgery (EGS) involves care of the most acutely ill and highest risk patients, and often comes at a high cost both financially and in patient survival and wellbeing.

A report published online recently by JAMA Surgery notes that seven procedures make up about 80% of all hospital admissions, deaths, complications, and inpatient costs attributable to operative emergency general surgery nationwide.

Those procedures are far from rare, according to the study team led by Brigham & Women’s Hospital researchers. In fact, the more than 3 million patients admitted to U.S. hospitals each year for EGS diagnoses are more than the sum of all new cancer diagnoses, they point out.

For the study, the researchers reviewed data from the 2008-2011 National Inpatient Sample, including in the analysis adults with primary EGS diagnoses in line with the American Association for the Surgery of Trauma definition, admitted urgently or emergently, who underwent an operative procedure within two days of admission.

Investigators also ranked 35 procedure groups to account for national mortality and complication burden and assessed contributions to total EGS frequency, mortality, and hospital costs among ranked procedures.

With 421,476 patient encounters associated with operative EGS, weighted to represent 2.1 million nationally over the four-year study period, the overall mortality rate was found to be 1.2%, the complication rate was 15%, and average cost per admission was $13,241.

A final set of seven operative EGS procedures were identified, which collectively accounted for 80% of procedures, 80% of deaths, 79% of complications, and 80% of inpatient costs nationwide. Those include:

• partial colectomy,
• small-bowel resection,
• cholecystectomy, operative management of peptic ulcer disease,
• removal of peritoneal adhesions,
• appendectomy, and
• laparotomy.

"National quality benchmarks and cost reduction efforts should focus on these common, complicated, and costly EGS procedures," the authors write.

In an invited commentary, Martin G. Paul, MD, of Sibley Memorial Hospital at Johns Hopkins Medicine in Washington, DC, recommended continued studies to “provide direction for high-impact quality initiatives, emphasizing not just a reduction in complications but an earlier recognition of these particularly morbid adverse events,” as well as improved metrics.

Paul also emphasized that “national health policy needs to address the fact that we have a decreasing number of general surgeons facing a growing burden, and appropriate resources and strategic planning need to be directed toward correcting this.”

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