Work hours, cardiac rehab, and more

Research summaries from ACP Hospitalist Weekly.

Errors less likely among ICU residents working longer rather than shorter shifts

Resident physicians working extended shifts were less likely to make serious errors than those working shorter shifts in a recent study.

Researchers performed a multicenter cluster-randomized crossover trial that compared extended-duration with non-extended-duration shifts among pediatric residents at six U.S. ICUs. Extended-duration schedules included shifts of 24 hours or more and served as the control. In the intervention schedules, extended shifts were eliminated and residents were cycled through day and night shifts of 16 hours or less. Each site began a two-year trial at a different time, with sites paired by start date. One site from each pair was randomly assigned to start with the control schedule while the other started with the intervention schedule. There was a four-month wash-in interval before the study began, followed by eight months of data collection. After another four-month wash-in interval, the sites crossed over to the other schedule, and researchers collected another eight months of data. The study's primary outcome was serious medical errors, as assessed by intensive surveillance that included direct observation and chart review. The study also assessed data on residents' work schedules, sleep, workload, and other factors. Results were published June 25 by the New England Journal of Medicine.

Overall, 172 residents completed 200 rotations on the control schedule, and 188 completed 210 rotations on the intervention schedule. The types of patients in the ICU were similar during each of the two work schedules. However, residents' workload was higher during the intervention schedules than during the control schedules (mean ICU patients per resident, 8.8±2.8 vs. 6.7±2.2, respectively). Residents made more serious errors during the intervention schedules than the control schedules (97.1 vs. 79.0 per 1,000 patient-days; relative risk, 1.53 [95% CI, 1.37 to 1.72]; P<0.001), and there were also more serious errors unitwide (181.3 vs. 131.5 per 1,000 patient-days; relative risk, 1.56 [95% CI, 1.43 to 1.71]). Error rates varied widely by site, with lower rates during the intervention schedules at one site, similar rates at two sites, and higher rates during the intervention schedules at three sites.

The researchers noted that data collection may have varied across sites, that other site-level factors, such as attending supervision, may have influenced their findings, and that their results may not be generalizable to other settings. In addition, a secondary analysis indicated potential confounding by increases in workload with the intervention schedule, although this finding should be considered exploratory, they said. The researchers concluded that residents on ICU rotations in their study were more likely to make serious medical errors while working a schedule that eliminated extended work shifts versus a schedule that included shifts lasting 24 hours or more. They also noted that while residents' workload was heavier on the intervention schedule, their sleep and neurobehavioral performance improved.

“A decade ago, the National Academy of Medicine recommended that resident physician work-hour reduction should not occur without an investment of resources to support adequate staffing and infrastructure. Excessive work hours degrade patient safety, but so too do excessive workloads and poor handoffs,” the authors wrote. “The results of our trial suggest that future interventions to address the persistent patient safety problems in academic health centers must address and rigorously evaluate all these challenges concurrently.”

Educational reminders by mail and phone increased uptake of cardiac rehab after MI

Educational reminders, delivered to patients by mail and phone, may increase the likelihood of completing cardiac rehabilitation after a myocardial infarction (MI), a randomized controlled trial found.

For the Interventions Supporting Long term Adherence aNd Decreasing cardiovascular events after MI (ISLAND) trial, researchers at nine cardiac centers in Ontario, Canada, used a centralized cardiac registry to enroll patients with obstructive coronary artery disease after an MI. They randomly assigned participants 1:1:1 to usual care (i.e., unstandardized communication between the hospital team, the primary care clinician, and, when relevant, the outpatient internist or cardiologist), a series of five mailed educational reminders, or mailed reminders plus phone calls. The phone calls were delivered first by an interactive automated system to screen for nonadherence to treatment, then followed up by trained lay health workers as necessary. Interventions were coordinated centrally but delivered from each patient's hospital site. The two primary outcomes were completion of cardiac rehabilitation and adherence to recommended medication. Blinded assessors collected data through patient report and from administrative health databases at 12 months. Results were published online on June 10 by The BMJ.

Image by Getty Images
Image by Getty Images

Of 2,632 patients (mean age, 66 years; 71% men), 876 were randomized to usual care, 878 were randomized to mail only, and 878 were randomized to the full intervention. Of the respondents, 174 (27%) of 643 in the usual care group, 200 (32%) of 628 in the mail-only group, and 196 (37%) of 531 in the mail-plus-phone group completed cardiac rehabilitation. Patients in the mail-plus-phone group were more likely to complete cardiac rehabilitation than those who received usual care (adjusted odds ratio, 1.55; 95% CI, 1.18 to 2.03). With regard to adherence to statins, antiplatelets, beta-blockers, and angiotensin system inhibitors, between-group differences were not significant. In the mail-plus-phone group, 11.7%, 6.0%, 14.4%, 32.9%, and 35.0% reported adherence to zero, one, two, three, and four drug classes after one year, respectively, compared with 12.5%, 6.8%, 13.6%, 30.2%, and 36.8% in the mail-only group and 12.2%, 8.4%, 13.1%, 30.3%, and 36.1% in the usual care group, respectively (odds ratios, 0.98 [95% CI, 0.81 to 1.19] for mail-only vs. usual care and 0.99 [95% CI, 0.82 to 1.20] for full intervention vs. usual care).

One limitation of the trial was patient self-reporting of the primary outcomes, the authors noted. They added that some enrolled patients were excluded after randomization because they did not meet eligibility criteria and that loss to follow-up was higher than expected.

Nearly half of surveyed hospitals told patients, caregivers to share portal passwords

A substantial portion of U.S. hospitals may encourage password sharing between patients and their caregivers, despite the security risks of sharing login credentials, a recent study found.

Researchers surveyed hospital personnel from May 21, 2018, to Dec. 20, 2018, to obtain information on proxy account availability, password sharing, and patient control of their own information. An interviewer posing as the daughter of an older adult patient called each hospital to ask about its patient portal practices using a structured questionnaire. The randomly selected sample comprised one independent hospital and one health system-affiliated general medical hospital from every state and the District of Columbia. Specialty hospitals and those that did not have a patient portal were excluded. The primary outcome was the proportion of hospitals that provided proxy accounts to caregivers of adult patients. Secondary outcomes were the proportion of hospitals with personnel who endorsed password sharing with caregivers and the proportion that allowed adult patients to limit the types of information available to caregivers. Results were published online on May 4 by JAMA Internal Medicine.

Of 102 hospitals (51 independent and 51 affiliated with health systems), 69 (68%) provided proxy accounts to caregivers of adult patients, and 26 (25%) did not; at the remaining 7 (7%) hospitals, the surveyed personnel did not know if proxy accounts were available. In the 94 hospitals asked about password sharing between the patient and caregiver, personnel in 42 hospitals (45%) endorsed the practice. Among hospitals that provided proxy accounts, 19% (13 of 69) offered controls that enabled patients to restrict the types of information their proxies could see.

Among other limitations of the study, the authors noted that because the hospital sample was stratified according to ownership, the results are reflective of practices therein but are not nationally representative overall. “Although we acknowledge that the responses of the personnel we surveyed may not reflect their respective hospital's stated policies, at a minimum our findings indicate a need for rigorous training in proper security practices,” they added.

The results “highlight a long-standing practice that has troublesome implications for patient privacy. . . . Clinicians cannot be confident about whom they are communicating with, care partners may become privy to information a patient may not want to share, and health care organizations may be violating their patients' right to privacy,” an accompanying commentary noted.

To increase the likelihood that caregivers can use patient portals effectively, the commentary authors suggested that vendors simplify proxy registration and that Congress modernize HIPAA to ensure that privacy rules also cover third-party applications' access to electronic health records. In addition, health care systems should develop educational campaigns involving front desk staff, medical assistants, and clinicians to help ensure that portals are incorporated into clinical practice, they said.

Recommendations offered on managing patient bias

Medical centers should develop policies to address patient behavior that demeans clinicians on the basis of their social identity traits, such as race, ethnicity, sex, disability, gender presentation, and sexual orientation, according to a recent article on the subject.

Although most medical centers have policies on dealing with difficult patients, few have policies that address patient bias toward clinicians, according to a paper that was published online on July 14 in the Academia and the Profession section of Annals of Internal Medicine and appeared in the Sept. 15 issue. Barriers to drafting patient bias policies include the need for institutional leadership to engage in difficult conversations about race, sex, and other types of bias in the workplace, as well as the need to tailor policies to different roles and settings, the paper said. To guide medical centers in addressing this issue, experts from San Francisco and New York City presented recommendations, as well as a sample policy, for appropriate management of patients' biased conduct or requests for clinician reassignment.

According to the guidance, a medical center should:

  • write a policy that explicitly addresses patient bias;
  • establish procedures that account for a range of clinical roles and services;
  • develop trainee-specific procedures;
  • consider the needs of nurses;
  • create support for reporting incidents;
  • designate a team to support staff and implement procedures;
  • ensure appropriate tracking and data collection; and
  • ensure adequate training for confronting biased patient behavior.

This appeal to adopt policies addressing patients' biased conduct toward clinicians is one of many calls to action that medical centers face, the authors noted. “However, quiet acceptance of biased patient behavior is not a defensible norm for medical centers,” they wrote. “The need for policies is compelling because they may not only help medical centers avoid unnecessary legal liability but may also contribute to the creation of a more effective and inclusive workplace.”

While ethically informed institutional policies are essential for coordinating an organization's response to patient bias, “Fair and transparent policies are not enough,” an accompanying editorial said. “Institutions and clinicians themselves should also make and clearly communicate a strong ethical commitment to zero tolerance for discrimination and demeaning behavior in all directions.”

Checklist use before intubation did not improve most outcomes

Use of checklists is not associated with improved survival in critically ill patients undergoing endotracheal intubation, a systematic review and meta-analysis found.

Researchers looked at studies published between Jan. 1, 1960, and June 1, 2019, to assess whether the available evidence showed an association of preparatory preintubation checklist use with improved outcomes. Included studies were randomized clinical trials or observational human studies that compared checklist use with any comparator for endotracheal intubation and assessed one of the predefined outcomes. The primary outcome was mortality, and secondary outcomes included first-attempt success and known complications of endotracheal intubation (e.g., esophageal intubation, hypoxia, hypotension, and cardiac arrest). Results were published on July 2 by JAMA Network Open.

Overall, 10 observational studies and one randomized clinical trial with a total of 3,261 patients met the inclusion criteria. The randomized trial and three observational studies had a low risk of bias. Checklist use was not associated with decreased mortality in five studies of 2,095 patients, with a relative risk of 0.97 (95% CI, 0.80 to 1.18). Checklist use was associated with a decrease in hypoxic events in eight studies of 3,010 patients, with a relative risk of 0.75 (95% CI, 0.59 to 0.95), but no other secondary outcomes. However, the association with fewer hypoxic events was no longer significant when the analysis was restricted to studies at low risk of bias.

Among other limitations, none of the included studies contained data for all of the predefined outcomes, and only five studies provided results for the primary outcome, the authors noted. In addition, only four included studies had a low risk of bias.

The findings suggest that there is no significant benefit of using a preintubation checklist to the experienced proceduralist or to the patient, an accompanying commentary noted. However, it remains unknown whether use of such checklists may improve outcomes in limited-resource settings or in situations where there is limited procedural experience, the commentary said.

“Practitioners who hold a prior belief that checklist use improves important outcomes during tracheal intubation should not be distressed by these data,” the author wrote. “The teaching of tracheal intubation, as with most procedures, still involves at least a verbal checklist performed between an experienced instructor and inexperienced trainee.”