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Article 1
Accuracy of Laboratory Data Communication on ICU Daily Rounds Using an Electronic Health Record. Artis KA, Dyer E, Mohan V, Gold JA. Crit Care Med. 2017 Feb;45(2):179-186.
This study was conducted as an observational study at a single US institution. Rounds in the Intensive Care Unit were audited for the purpose of the study by two senior ICU fellows, with the purpose of determining the accuracy of the laboratory information presented on ICU rounds. Interns were the most frequent presenters on rounds, and they had typically pre-processed information (“pre-rounds”) before attending ICU rounds. The auditing fellows had a defined system for determining if laboratory data had been misrepresented, and a well-defined system for classifying partially represented data, which was consistently applied throughout the study period. Additionally, the auditors described which data seemed to be misrepresented most often, and which types of misrepresentations occurred most often.
Overall, trainees correctly and accurately presented only 61.1% of data over 301 patient rounding audits (4,945 laboratory test observations). The most common misrepresentation was omission of lab data (79.6%), followed by reporting old data (12.0%). There is extensive description of the details of the observations, including that high census days had significantly lower accuracy 56.7% accuracy on high census days vs 63.5% accuracy on low census days, p=0.0001). Only a small fraction of the errors were caught on rounds (5.3% -9.0%, RR 0.59 95%CI 0.40-0.87) Year of training, time of year, or familiarity with attending were not associated with statistical differences in accuracy. Additionally, CBC results were the most accurately reported, while PTT (for heparin) was least accurately reported. These observations were despite the fact that an Electronic Medical Record was in use during the study period, and despite the fact that the attending physician was actively using the EMR 58% of the time. Residents and students used pre-rounding notes to collate lab information instead of the EMR.
This study demonstrates that there is still substantial inaccuracy in data used to make medical decisions, despite pervasive investment in technological advances to address these inaccuracies. Certainly local procedures and protocols may differ with respect to rounding patterns, however still the human element is likely a persistent cause of medical error. Even in cases where the attending on rounds was actively logged into the EMR, there were still substantial errors encountered on rounds, which is fascinating and may speak to generational differences in facility with computer technology. Regardless, this article serves as a clear call to verify information presented on rounds.
Article 2
Evaluation of RBC Transfusion Practice in Adult ICUs and the Effect of Restrictive Transfusion Protocols on Routine Care. Seitz KP, Sevransky JE, Martin GS, Roback JD, Murphy DJ. Crit Care Med. 2017 Feb;45(2):271-281.
This study is a planned secondary analysis of a large, outcomes study (US Critical Illness and Injury Trails Group- Critical Illness Outcomes Study) that sampled data from 59 ICUS at 36 Hospitals. They collected data from 6,179 patients, which yielded 771 transfused patients. Patients in hospitals with restrictive transfusion protocols (RTP) were older (61.9 vs. 57.9, p<0.001); more often white (76% vs. 62%and less often admitted to ICU for CNS, circulatory, respiratory or trauma diagnoses. Patients in ICUs whose treatment was not guided by an RTP were more likely Medical ICU patients (48% MICU patients did not have RTP vs. 36% MICU patients had RTP).
The authors found that although transfusion is still very common, and despite the fact that even with an RTP, patients were still transfused outside of the protocols’ guidelines (only 27% were transfused before they reached the protocols’ lower threshold), the presence of an RTP was associated with a reduction in the probability of transfusion across the spectrum of anemia (reduction in the odds of transfusion as high as 31% in the intended range (21% < hematocrit > 30%). The authors conclude that a RTP does indeed reduce transfusions, even though it is not always strictly followed.
It is interesting that there is no discussion of transfusion for trauma patients with massive bleeding but without clinically documented anemia in the cases of severe, ongoing bleeding, even though trauma made up 6 % of the No-RTP patient group and 9% of the RTP group. However, although a confounder, these trauma patients would not be sufficient to skew the results either way. It is difficult to determine if any of the trauma sample were within 24 hours of injury or not, possibly a determining factor for transfusion outside of the protocol threshold. Despite this very minor point, these data suggests that RTPs likely change culture of freer transfusions, and improve efficient use of scarce blood resources without compromising patient outcomes. It appears that really, this may represent a culture change, and it would be very interesting to see if the off-protocol transfusions decreased as familiarity with more restrictive transfusion triggers increases over time. Nonetheless, this article represents evidence that just the attempts to restrict transfusion, while not successful in every case, still exert an effect on overall institutional practices.
Article 3
Effectiveness of low-molecular-weight heparin versus unfractionated heparin to prevent pulmonary embolism following major trauma: A propensity-matched analysis. Byrne JP, Geerts W, Mason SA, Gomez D, Hoeft C, Murphy R, Neal M, Nathens AB. J Trauma Acute Care Surg. 2017 Feb;82(2):252-262.
In this large, retrospective database study, over 153,000 patient charts were reviewed for PE after major trauma (defined as an AIS >3 for any body system). Data were analyzed using propensity score matching methodology, as well as multivariate logistic regression and center-level analysis.
The authors demonstrated, by each of three statistical methods, that LMWH decreased pulmonary embolism over patients prescribed unfractionated heparin. Using the propensity score matching, the odds ratio (OR) for PE was 0.56 (95% CI 0.50-0.63); using multivariate logistic regression, the OR was 0.59 (95%CI 0.54 to 0.65) and for the center-level analysis, centers in the highest quartile of LMWH use were nearly 50 times as likely to use LMWH, and the OR for PE was, again, 0.59 (95% CI 0.48 to 0.74).
This study demonstrates that LMWH protects better against PE than UH; the propensity score matching methodology as performed is intended to elucidate causal relationships, however there may be confounding with unobserved and unobservable covariates. The authors, to address this possible weakness, determined that the OR for such an unobserved covariate would have to be >5, making a confounder of this magnitude unlikely to be unobserved.
There are, however, other possible limitations of this study. There really is no discussion of complications that may be due to LMWH usage (over UH), an element which likely factors into a decision to choose UH over LMWH. Especially for TBI and intracranial hemorrhage, physicians and providers may select UH for its shorter half life and reduced risk of recurrent bleeding. There is no primary data cited to refute the possibility of increased complications, as this was not the intent of the study. However, the authors do cite past published research to refute complications in the patient population studied. Although the body of literature on this question is certainly replete, the grades of evidence and the scientific rigor of those data may not be quite as meticulous as these data, which clearly demonstrates a decrease in PE when LMWH is used over UH for VTE prophylaxis. Altogether, this article represents valuable and high grade data that LMWH is valuable over UH for prevention of PE.
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