Do Laboratory Blood Tests Change Medical Care in Patients Hospitalized with Community-Acquired Pneumonia?

Background and Objectives: The prevalence of inappropriate laboratory testing is believed to be high, but only a limited number of studies have reviewed medical charts to determine whether tests impact medical care. Materials and Methods: From the electronic database, we selected 500 consecutive patients with community-acquired pneumonia who were hospitalized between January 2020 and October 2021. We excluded eight patients who had COVID-19, but were not identified in the database, and were only identified after chart review. To assess the impact of tests on medical care, we conducted a thorough review of the patients' charts. Results: The age of the patients was 78 ± 16 years, with 42.3% female (n = 208) hospitalized for a median of 4 days (25-75%, 3-6 days). There were 27957 laboratory test results during 2690 hospital days (10.4 tests per day of hospitalization). Of the 2997 tests carried out on admission 5.7% (n = 170) resulted in changes of medical care in 34.5% (170/492) of the patients, nearly all from the results of electrolytes, renal function tests, and serum glucose measurements. Tests that did not lead to any decision on medical care included 75.8% (7181/9478) on admission and 86.0% (15,898/18,479) on repetitive testing, i.e., repetitive testing accounted for 68.9% (15,898/23,079) of tests that did not change medical care. By excluding tests that did not change medical care, the overall testing rate would decrease by 82.6% (23,079/27,947), and from 10.4 tests per day to 2.1 tests per day. Conclusions: We conclude that the estimate of the overuse of laboratory testing, which includes all testing that does not change patient care, is much higher than reported using other methodologies. Most of the overuse was from repetitive testing that included unnecessary testing in patients without admission test results that changed medical care. Further investigation is needed to determine if these findings can be applied to patients with diverse health conditions and in different healthcare settings.

The Norton scale is an important predictor of in-hospital mortality in internal medicine patients

BACKGROUND

The Norton scale, a marker of patient frailty used to predict the risk of pressure ulcers, but the predictive value of the Norton scale for in-hospital mortality after adjustment for a wide range of demographic, and abnormal admission laboratory test results shown in themselves to have a high predictive value for in-hospital mortality is unclear.

AIM

The study aims to determine the value of the Norton scale and the presence of a urinary catheter in predicting in hospital mortality.

METHODS

The study population included all acutely admitted adult patients in 2020 through October 2021 to one of three internal medicine departments at the Laniado Hospital, a regional hospital with 400 beds in Israel. The main objective was to (a) identify the variables associated with the Norton Scale and (b) determine whether it predicts in-hospital mortality after adjustment for these variables.

RESULTS

The Norton scale was associated with an older age, female gender, presence of a urinary catheter, and abnormal laboratory tests. The odds of in-hospital mortality in those with intermediate, high, and very high Norton scale risk groups were 3.10 (2.23-3.56), 6.48 (4.02-10.46), and 12.27 (7.37-20.44), respectively, after adjustment for the remaining predictors. Adding the Norton scale and the presence of a urinary catheter to the prediction logistic regression model that included age, gender, and abnormal laboratory test results increased the c-statistic from 0.870 (0.864-0.876) to 0.908 (0.902-0.913).

CONCLUSIONS

The Norton scale and presence of a urinary catheter are important predictors of in-hospital mortality in acutely hospitalized adults in internal medicine departments.

Asymptomatic Microscopic Hematuria in Inpatient Nonsurgical Adults

OBJECTIVES

This study sought to determine the proportion of nonsurgical inpatients with asymptomatic microscopic hematuria (AMH) who qualified for urologic investigation according to consensus guidelines.

METHODS

The study population included all patients acutely admitted to the internal medicine departments of Israeli regional hospitals between 2014 and 2017.

RESULTS

Of 29,086 consecutive admissions, 10,116 (34.8%) underwent dipstick urinalysis and 8,389 (28.8%) underwent reflex microscopic urinalysis. After the exclusion of patients with a urethral catheter or a positive urine culture, 2,206 had 3 or more RBCs per high-power field, and as many as 2,052 (7.1% of the entire cohort and 24.4% of all patients undergoing microscopic urinalysis) met the criteria for a urologic workup.

CONCLUSIONS

We conclude that according to the consensus guidelines, an unreasonably high proportion of hospitalized nonsurgical patients would be referred for a urologic workup of uncertain clinical utility because of an incidental AMH finding.

Observational study of peripheral intravenous catheter outcomes in an internal medicine department

BACKGROUND

In elderly patients hospitalised in internal medicine departments, risk factors, preferable placement area and methods of securement of short peripheral venous catheters (SPVC) a unclear.

AIM

To determine the incidence and risk factors of adverse events using a transparent bordered dressing for securement in the dorsum of the hand or cubital fossa in consecutive patients hospitalised in an internal medicine department.

METHODS

In a prospective observational study of patients admitted to a regional hospital with a SPVC, the dependent variable was the need to replace the catheter because of an adverse event (phlebitis, accidental removal, infiltration/occlusion). The independent variables were age, gender, disorientation, placement area, intravenous antibiotic therapy and indwelling time. Risk factors were determined by Cox regression model analysis.

RESULTS

There were 709 catheters placed in 499 patients. Per catheter placed the mean age was 75 ± 17 years. Accidental removal, infiltration/obstruction and phlebitis occurred in 21.5, 16.2 and 15.0 events per 1000 days respectively. There was a significantly increased risk on Day 3 compared to Days 2 and 4. An older age, intravenous antibiotics and disorientation increased the hazard for accidental displacement, whereas phlebitis was associated only with intravenous antibiotics and occlusion/infiltration only with age.

CONCLUSIONS

The observed low rates of adverse events suggests that placement in the dorsum of the hand or cubital fossa secured by a transparent dressing is acceptable. It is important to consider the indwelling catheter time when studying adverse events, and elderly patients, disoriented patients and/or patients receiving intravenous antibiotics deserve special attention.

The presence of a urinary catheter is an important predictor of in-hospital mortality in internal medicine patients

RATIONALE AND OBJECTIVE

Mortality rates are used to assess the quality of hospital care after appropriate adjustment for case-mix. Urinary catheters are frequent in hospitalized adults and might be a marker of patient frailty and illness severity. However, we know of no attempts to estimate the predictive value of indwelling catheters for specific patient outcomes. The objective of the present study was to (a) identify the variables associated with the presence of a urinary catheter and (b) determine whether it predicts in-hospital mortality after adjustment for these variables.

METHODS

The study population included all acutely admitted adult patients in 2020 (exploratory cohort) and January-October 2021 (validation cohort) to internal medicine, cardiology and intensive care departments at the Laniado Hospital, a regional hospital with 400 beds in Israel. There were no exclusion criteria. The predictor variables were the presence of a urinary catheter on admission, age, gender, comorbidities and admission laboratory test results. We used bivariate and multivariate logistic regression to test the associations between the presence of a urinary catheter and mortality after adjustment for the remaining independent variables on admission.

RESULTS

The presence of a urinary catheter was associated with other independent variables. In 2020, the odds of in-hospital mortality in patients with a urinary catheter before and after adjustment for the remaining predictors were 14.3 (11.6-17.7) and 6.05 (4.78-7.65), respectively. Adding the presence of a urinary catheter to the prediction logistic regression model increased its c-statistic from 0.887 (0.880-0.894) to 0.907 (0.901-0.913). The results of the validation cohort reduplicated those of the exploratory cohort.

CONCLUSIONS

The presence of a urinary catheter on admission is an important and independent predictor of in-hospital mortality in acutely hospitalized adults in internal medicine departments.

Stop routine microscopic urinalysis in hospitalized patients with dipstick abnormalities?

BACKGROUND

Restricting the performance of microscopic urinalyses only to patients in whom it was specifically requested has been shown to reduce their number in laboratories servicing both inpatients and outpatients.

OBJECTIVE

To determine the effect of such restriction solely in in-patients in a 400-bed regional hospital.

METHODS

In 2017, we discontinued routine ('reflex') microscopic urinalysis for all positive dipstick results, and restricted such testing to in-patients in whom it was specifically requested by a doctor. We compared the numbers of patients in three internal medicine departments who had a urinalysis over 2-year periods before and after 2017, and reviewed doctors' complaints.

RESULTS

Before 2017, more than 80% of all dipstick tested samples had one or more abnormalities that led to a microscopic examination. Discontinuation of reflex microscopy reduced microscopic urinalysis to less than 10% of all patients with dipsticks on admission. Requests for repeat urinalysis decreased from 4.3% to 2.5% and there were no complaints after the change in policy.

CONCLUSIONS

Discontinuation of a 'reflex' microscopic urinalysis in patients with abnormal dipstick results did not increase repeat urine testing. Doctors apparently felt that the microscopic urinalysis does not have clinical utility in the vast majority of hospitalized adult patients.

An Index Predicting Histological Acute Cholecystitis in Patients Undergoing an Urgent Laparoscopic Cholecystectomy

BACKGROUND

It is important to predict acute cholecystitis (AC) before a laparoscopic cholecystectomy because inflammation of the gallbladder predicts the need for open conversion and subsequent morbidity after a laparoscopic cholecystectomy.

OBJECTIVES

To create an index based on clinical, laboratory, and ultrasound criteria on admission that will predict AC on pathological examination in patients presenting acutely.

METHODS

We retrospectively reviewed consecutive cases of emergency laparoscopic cholecystectomies conducted by three experienced surgeons between 1 October 2014 and 31 January 2018. Independent variables were age, sex, presenting symptoms, admission laboratory tests, and ultrasound findings. The outcome variable was AC on histological examination. An index was created from all variables that added significantly to the logistic regression analysis.

RESULTS

Eight variables that contributed significantly to the model, included age, male sex, vomiting on admission, an increased proportion of neutrophils, a normal aspartate aminotransferase test, a normal serum amylase test result, a thick gall bladder wall, and pericholecystic fluid. An index of ≤ 2 to ≥ 8 created from those variables had a graded risk for AC of 1.8% to 92.0% with a c-statistic of 0.86 (95% confidence interval 0.81-0.91). Operating time and bleeding increased in those with a higher index.

CONCLUSIONS

An index including age, sex, symptoms, and selected laboratory results as well as ultrasound characteristics had an excellent graded risk in the prediction of histological AC that was associated with operating time and an increased risk of bleeding during the operation.

Parameters of the complete blood count predict in hospital mortality

INTRODUCTION

Mortality rates are used to evaluate the quality of hospital care after adjusting for disease severity and, commonly also, for age, comorbidity, and laboratory data with only few parameters of the complete blood count (CBC).

OBJECTIVE

To identify the parameters of the CBC that predict independently in-hospital mortality of acutely admitted patients.

POPULATION

All patients were admitted to internal medicine, cardiology, and intensive care departments at the Laniado Hospital in Israel in 2018 and 2019.

VARIABLES

Independent variables were patients' age, sex, and parameters of the CBC. The outcome variable was in-hospital mortality.

ANALYSIS

Logistic regression. In 2018, we identified the variables that were associated with in-hospital mortality and validated this association in the 2019 cohort.

RESULTS

In the validation cohort, a model consisting of nine parameters that are commonly available in modern analyzers had a c-statistics (area under the receiver operator curve) of 0.86 and a 10%-90% risk gradient of 0%-21.4%. After including the proportions of large unstained cells, hypochromic, and macrocytic red cells, the c-statistic increased to 0.89, and the risk gradient to 0.1%-29.5%.

CONCLUSION

The commonly available parameters of the CBC predict in-hospital mortality. Addition of the proportions of hypochromic red cells, macrocytic red cells, and large unstained cells may improve the predictive value of the CBC.

Proteinuria in hospitalised internal medicine adult patients

RATIONALE

Dipstick proteinuria may be a sign of a renal disorder, false-positive or associated with acute disease, and consequently, transient in hospitalised patients.

OBJECTIVE

To assess (a) the prevalence of proteinuria in hospitalised patients; (b) its association with estimated glomerular filtration rate (eGFR), findings known to cause false-positive test results and indicators of acute disease and (c) the need for follow-up after discharge.

SETTING AND PARTICIPANTS

All patients who had a dipstick urinalysis on admission to medical wards of a 400-bed regional hospital in 2018-2019.

OUTCOME VARIABLE

Proteinuria.

INDEPENDENT VARIABLES

(a) Other findings on dipstick urinalysis; (b) patients' age, gender, presence of urinary catheter and eGFR and (c) white blood cell count (WBC) and fever.

RESULTS

Of 22 329 patients, 6609 (29.6%) had urinalysis. Of those, 2973 patients (45.0%) had proteinuria of ≥+1 (≥0.30 g/L). The variables independently associated with proteinuria were other dipstick findings known to cause false-positive test results, elevated WBC, fever on presentation, presence of a urethral catheter and a low eGFR. eGFR alone was a poor predictor of proteinuria (c-stat 0.62); however, addition of the remaining independent variables to the model significantly improved its predictive ability (c-stat 0.80).

CONCLUSIONS

Dipstick proteinuria is common in hospitalised patients. Although weakly associated with eGFR, proteinuria is mainly associated with confounding factors that may result in false-positive test results. The need for follow-up of proteinuria after discharge has questionable clinical utility and its high frequency would entail a considerable cost.

Value of Troponin in Predicting Hospital Mortality of Older Adult Patients without Suspected Acute Coronary Syndromes

OBJECTIVES

Some authors have recommended troponin measurement to stratify patient mortality risk, but it is unclear whether troponin values add to age and routine admission laboratory tests in the prediction of in-hospital mortality of older adult patients without suspected acute coronary syndrome (ACS). The aim of our study was to determine whether troponin testing adds significantly to routine admission laboratory testing in predicting in-hospital mortality in patients without a suspected ACS.

METHODS

In 2018-2019, we reviewed all acutely admitted patients aged 60 years or older to Internal Medicine wards of a regional hospital after excluding those admitted to intensive care or with chest pain. The independent variables were troponin, age, sex, and routine admission laboratory tests. The outcome measure was in-hospital mortality. We compared c-statistics and the observed 10% to 90% risk gradients using logistic regression models for age and routine laboratory testing before and after the addition of troponin.

RESULTS

The mortality risk gradient for age and admission laboratory tests was 0.2% to 29.5%. Adding troponin did not increase the gradient significantly (0.2%-34.6%, P = 0.170), and the 95% confidence intervals for the c-statistics overlapped, increasing from 0.845 (0.818-0.876) to 0.866 (0.839-0.892).

CONCLUSIONS

In older adult patients without suspected ACS, troponin testing did not improve the prediction of hospital mortality above that of a model including age and common admission blood tests. In the absence of suspected ACS, troponin testing is not needed to predict the hospital mortality of older adult patients.

A simple index predicting 30-day readmissions in acutely hospitalized patients

BACKGROUND

There are various models attempting to predict 30-day readmissions of acutely admitted internal medicine patients. However, it is uncertain how to create a parsimonious index that has equivalent predictive ability and can be extrapolated to other settings.

METHODS

We developed a regression equation to predict 30-day readmissions from all acute hospitalizations in internal medicine departments in a regional hospital in 2015-2016 and validated the model in 2019. The independent (predictor) variables were age, past hospitalizations, admission laboratory test results, length of stay in hospital and discharge diagnoses. We compared the predictive value of a logistic regression model and index that included discharge diagnoses and admission laboratory test results with one that included only age, past hospitalizations, and hospital length of stay.

RESULTS

Readmission rates were associated with age, time since last hospitalization, number of previous hospitalizations, and length of stay, as well as with a diagnosis of chronic obstructive lung disease and congestive heart failure and several laboratory data. Logistic regressions of the independent variables for 30-day readmission rates were similar in 2015-2016 and 2019. An index was derived from number of previous admissions to hospitals, time since last admission, age, and length of stay. In 2019, for every unit of the index, the odds of readmission increased by 1.33 (95% CI- 1.30-1.37), and ranged from 2.1% to 37.1%. Addition of discharge diagnoses and laboratory variables did not significantly improve the risk differentiation of the index. The c-statistic for the final parsimonious model was 0.704.

CONCLUSIONS

An index derived from the number of previous hospital admissions, days since last admission, age, and length of stay in days differentiated between the risks of readmission within 30 days without the need for discharge diagnosis and laboratory variables.

Head Computed Tomography Scans in Elderly Patients with Low Velocity Head trauma after a Fall

BACKGROUND

Recommendations for a head computed tomography (CT) scan in elderly patients without a loss of consciousness after a traumatic brain injury and without neurological findings on admission and who are not taking oral anticoagulant therapy, are discordant.

OBJECTIVES

To determine variables associated with intracranial hemorrhage (ICH) and the need for neurosurgery in elderly patients after low velocity head trauma.

METHODS

In a regional hospital, we retrospectively selected 206 consecutive patients aged ≥ 65 years with head CT scans ordered in the emergency department because of low velocity head trauma. Outcome variables were an ICH and neurological surgery. Independent variables included age, sex, disability, neurological findings, facial fractures, mental status, headache, head sutures, loss of consciousness, and anticoagulation therapy.

RESULTS

Fourteen patients presented with ICH (6.8%, 3.8-11.1%) and three (1.5%, 0.3-4.2%) with a neurosurgical procedure. One patient with a coma (0.5, 0.0-2.7) died 2 hours after presentation. All patients who required surgery or died had neurological findings. Reducing head CT scans by 97.1% (93.8-98.9%) would not have missed any patient with possible surgical utility. Twelve of the 14 patients (85.7%) with an ICH had neurological findings, post-trauma loss of consciousness or a facial fracture were not present in 83.5% (95% confidence interval 77.7-88.3) of the cohort.

CONCLUSIONS

None of our patients with neurological findings required neurosurgery. Careful palpation of the facial bones to identify facial fractures might aid in the decision whether to perform a head CT scan.

A simple index predicting mortality in acutely hospitalized patients

BACKGROUND

Mortality rates used to evaluate and improve the quality of hospital care are adjusted for comorbidity and disease severity. Comorbidity, measured by International Classification of Diseases codes, do not reflect the severity of the medical condition, that requires clinical assessments not available in electronic databases, and/or laboratory data with clinically relevant ranges to permit extrapolation from one setting to the next.

AIM

To propose a simple index predicting mortality in acutely hospitalized patients.

DESIGN

Retrospective cohort study with internal and external validation.

METHODS

The study populations were all acutely admitted patients in 2015-16, and in January 2019-November 2019 to internal medicine, cardiology and intensive care departments at the Laniado Hospital in Israel, and in 2002-19, at St. James Hospital, Ireland. Predictor variables were age and admission laboratory tests. The outcome variable was in-hospital mortality. Using logistic regression of the data in the 2015-16 Israeli cohort, we derived an index that included age groups and significant laboratory data.

RESULTS

In the Israeli 2015-16 cohort, the index predicted mortality rates from 0.2% to 32.0% with a c-statistic (area under the receiver operator characteristic curve) of 0.86. In the Israeli 2019 validation cohort, the index predicted mortality rates from 0.3% to 38.9% with a c-statistic of 0.87. An abbreviated index performed similarly in the Irish 2002-19 cohort.

CONCLUSIONS

Hospital mortality can be predicted by age and selected admission laboratory data without acquiring information from the patient's medical records. This permits an inexpensive comparison of performance of hospital departments.

The influence of mental status on reported local urinary tract symptoms in patients with bacteraemic urinary tract infections

AIM

In elderly patients with a urinary tract infection, the influence of mental status on the frequency of local urinary tract symptoms is uncertain. We aim to compare the frequency of reported local urinary tract symptoms between mentally intact and cognitively impaired older people with a bacteraemic urinary tract infection.

METHODS

We retrospectively selected consecutive patients aged 65 years or older hospitalised in internal medicine departments in a regional hospital from 1 January 2015 to 31 December 2016 if they had identical bacteria isolated from blood and urine cultures. Mentally intact patients were those who were alert on admission and throughout their hospitalisation and without a prior or new diagnosis of dementia.

RESULTS

Of 222 patients with a bacteraemic urinary tract infection, 125 (56.3%) did not have local urinary tract symptoms, 68.8% (86/125, 95% CI-60.7%-76.9%) cognitively impaired, compared with 40.2% (39/97, 95% CI-30.4%-50.7%) in those mentally intact (P < .001).

CONCLUSIONS

The absence of local urinary tract symptoms in elderly patients with a bacteraemic urinary tract infection is less frequent but common in those mentally intact, and should not preclude the need for a urine culture or antibiotic therapy.

Decreasing the Overuse of Troponin Testing- An Interventional Study in a Regional Hospital

INTRODUCTION

The purpose of this study was to determine the effect of recommendations to limit troponin testing to patients with either chest pain or ischemic electrocardiographic changes.

METHODS

We included all adult patients hospitalized in a regional hospital in internal medicine, cardiology, and intensive care departments in 2014-2016 and in 2019 after recommending limiting troponin testing to patients with either chest pain or ischemic electrocardiographic changes.

RESULTS

After the intervention, testing decreased from 51.5% (11,634/22,581) to 34.6% (3417/9882). However, if only those with ischemia or chest pain were tested, the frequency would be 9.4% (924/9882) with a 95% confidence interval of 8.8%-9.9%. Variables increasing the odds of ordering a troponin test were older age, male sex, a discharge diagnosis of tachyarrhythmia, congestive heart failure, and dizziness or syncope as well as lower albumin and higher glucose, uric acid, and blood urea nitrogen test results. There were lower odds in those with nonspecific symptoms and infections of the skin, soft tissues, and the urinary tract. Auditing increased the effectiveness of the intervention in 1 internal medicine department (odds ratio 0.70, 95% confidence limit 0.60-0.82) after adjustment for other significant independent variables. The area under the curve was 0.713.

CONCLUSION

We found that an educational program with clear recommendations decreased the proportion of patients with troponin testing in hospitalized internal medicine departments, but the intervention was only partially effective and did not include patients with congestive heart failure and other conditions in which expert recommendations for testing are discordant.

Decreasing urine culture rates in hospitalized internal medicine patients

BACKGROUND

There are no previous studies on decreasing urine cultures in hospitalized internal medicine patients by a combination of physician education and reflex cancellation of urine cultures in those with a negative dipstick urinalysis.

METHODS

We compared urine culture rates in all hospitalized internal medicine patients 18 years or older before intervening (2016), during medical education efforts (2017), and after reflex cancellation of urine cultures in patients with a negative dipstick (negative leukocyte esterase and nitrites) (2018, 2019).

RESULTS

Compared to the preintervention period (2016), urine cultures decreased from a baseline of 32.7% (95% confidence intervals [95%CI]-31.7-33.6) to 26.6% (95%CI-25.8%-27.4%) after medical education efforts, and to 18.2% (95%CI-17.4%-19.0%) and to 15.2 (95%CI-14.5%-15.9%) during the 2 years after reflex cancellation of the urine cultures. There were no physician complaints and there were no urine cultures orders after reflex cancellation.

CONCLUSIONS

We conclude that physician education and cancellation of urine cultures in those with negative dipsticks resulted in a persistent decrease in urine cultures of around 50%. Extrapolation to other settings requires caution since the results are dependent on patient selection, physician behavior, and methods of urine testing.

Bacterial Resistance to Cephalosporin Treatment in Elderly Stable Patients Hospitalized With a Urinary Tract Infection

BACKGROUND

It is unclear if parenteral cephalosporin treatment is appropriate in stable elderly patients hospitalized with a urinary tract infection (UTI) in settings with a high prevalence of bacterial resistant organisms.

METHODS

We selected 934 consecutive stable patients aged ≥65 years with a UTI, 94.4% (n = 882) treated with a parenteral cephalosporin. Patients were divided into those with and without bacterial resistance to initial antibiotic therapy (BRIAT). Outcome measures were response to antibiotic therapy at 72 hours, prolonged hospitalization (>5 days) and mortality.

RESULTS

There were 316 patients (33.8%) with BRIAT. At 72 hours, 33.9% (107/316) did not respond to initial treatment. The odds of a prolonged hospitalization was 2.1 (95% confidence interval-1.6-2.9), but no patient with BRIAT died from urosepsis (0%, 95% confidence interval-0-1.2%).

CONCLUSIONS

In elderly stable patients hospitalized with a UTI, treatment with a parenteral cephalosporin might be appropriate despite a high prevalence of resistant organisms.

Prevalence, impact, and management strategies for asymptomatic bacteriuria in the acute care elderly patient: a review of the current literature

Introduction: It is unclear how to prevent the negative impact of inappropriate urine cultures in older acute care patients who have a high rate of asymptomatic bacteriuria.Areas covered: A nonsystematic literature review of the definition, impact, and management of elderly acute care patients with asymptomatic bacteriuria (ASB).Expert opinion: In the elderly, patients with ASB include those with extra-urinary tract diseases (e.g. pneumonia) and those with symptoms/signs that resolve without antibiotic therapy, but the diagnosis of ASB is unclear in febrile patients responding to antibiotics. We consider four management strategies that could decrease the negative impact of culturing the urine including unnecessary antibiotic therapy in those with ASB: (1) Prevent urine testing in patients with extra-urinary tract reasons for their acute care (2) Cancel urine cultures if the urine dipstick is negative. (3) Avoid catheterization in stable patients who cannot provide a urine specimen on demand and (4) Withhold antibiotics in stable non-febrile elderly patients who do not have new local urinary tract symptoms or decompensation on follow-up, and pursue further investigations for another etiology/diagnosis.

Chest Radiography Should Be Requested Only on Admission Based on Clinical Grounds

OBJECTIVES

To determine the clinical utility and adverse consequences of routine admission chest x-ray (CXR) findings in patients with and without respiratory complaints and/or an abnormal chest examination.

METHODS

In this prospective cohort study in an internal medicine department, we selected 273 patients and determined outcomes by chart review and physician interviews. The patients were divided into those with and without respiratory tract symptoms and/or findings on chest examination. The outcome variables were appropriate or inappropriate changes in treatment based on CXR findings.

RESULTS

Of the 35 patients with respiratory tract symptoms/signs, 7 (20%) had a change in therapy based on CXR findings, which was effective in 5 of them. In the other 238 patients, an unexpected pleural empyema was detected in a hypotensive dialysis patient (0.4%, 95% confidence interval 0-2.3). Besides costs and radiation exposure, major adverse effects included two patients (0.8%, 95% confidence interval 0.1-3.0) with a false-positive test result that resulted in inappropriate hospitalizations and antibiotic therapy. In patients without respiratory tract symptoms or findings on physical examination, the clinical benefits and major adverse consequences were uncommon.

CONCLUSIONS

Admission CXRs in patients without respiratory tract symptoms or findings are unwarranted except perhaps in older adult patients with comorbidities and an unclear admitting diagnosis.

The clinical utility and adverse consequences of the complete blood count in an internal medicine department

The clinical utility and adverse consequences of the admission and follow-up complete blood count (CBC) in hospitalised patients are unclear. We selected 273 patients chosen from a single internal medicine department. To determine clinical utility and adverse consequences, we interviewed attending physicians and reviewed patients' charts. There were 12 (4.4%) patients hospitalised because of the CBC test result, six referred appropriately with a low haemoglobin concentration found in outpatient clinics and six (2.2%) patients (95% confidence interval 0.8-4.7%) inappropriately hospitalised because of incidental findings. In the hospital, according to the physicians, nearly all treatment changes made were for blood transfusions that were not indicated in 18 (6.6%) patients (95% confidence interval 4.0-10.2%). The only unexpected findings were in four patients with an indication for a blood transfusion admitted with an acute coronary syndrome and haemoglobin values 8-9.9 g/dL, and in one bedridden patient with dementia with acute myeloid leukaemia. There were 290 follow-up CBC tests not resulting in differential treatment. We conclude that admission CBC tests commonly lead to adverse consequences, due to physician errors in judgement. Incidental findings of anaemia justify CBC testing in patients with an acute coronary event. The rare patient with an incidental finding resulting in appropriate differential treatment might justify non-selective admission CBC counts, if physician education reduces the rate of inappropriate blood transfusions.

[ELDERLY HOSPITALIZED FEBRILE PATIENTS WITH A SUSPECTED URINARY TRACT INFECTION: DIAGNOSTIC AND THERAPEUTIC APPROACH]

Since the urinary tract is thought to be one of the common sources of fever in hospitalized geriatric patients, urine analysis and urine cultures are routinely ordered in patients with and without urinary tract symptoms. The widespread lack of understanding of the uncertainties in the diagnosis and treatment of a symptomatic urinary tract infection (UTI) leads to unnecessary laboratory testing, and inappropriate antibiotic therapy. We present evidence for the following proposal that on the one hand will limit urine cultures and unnecessary antibiotic therapy without compromising patient safety and on the other hand will ensure proper antibiotic therapy. (1) Patients with extra-urinary sources for their fever should not have a urinalysis or urine culture. (2) In-and-out urinary catheterization procedures to obtain a sample should be limited (3) Patients without a positive dipstick test result do not need a urine culture in some settings. (4) A negative microscopic urinalysis after a positive dipstick test does not rule out a symptomatic UTI. (5) Febrile elderly patients without evidence of end organ damage can be followed-up carefully without antibiotic therapy. (6) Patients with septic shock require immediate antibiotic treatment with a carbapenem. It is unclear however, what to do with patients who have evidence of end organ damage variously defined. Whether these patients need immediate antibiotic treatment with or without coverage of ESBL-producing bacteria to decrease the risk for in-hospital mortality is an important question that requires randomized controlled studies.

Von Willebrand Factor and Mitral Valve Prolapse

The levels of von Willebrand factor (vWF: Ag) were measured in 27 patients with mitral valve prolapse (MVP) and compared to 27 age matched controls. Decreased levels of vWF:Ag (<80%) were found in 59% (16/27) of those with MVP compared to only 7% (2/27) of the controls (p <0.001). Mean vWF: Ag levels were also significantly lower in those with MVP (68 ± 30% versus 100 ± 23%, p <0.001). In those with MVP and congestive heart failure secondary to ruptured chordae tendineae, however, the mean level of vWF:Ag was not significantly different from control values (95 ± 32). There was an increased incidence of recurrent nose bleeds in those with MVP and low levels of vWF: Ag. We conclude that there is a relationship between MVP and low levels of vWF:Ag which may explain the increased incidence of epistaxis in such patients. Increased release of vWF: Ag in those with MVP and concomitant congestive heart failure may account for the normal levels found in this subgroup.

Minimal Use of Opioids for Pain Relief in an Internal Medicine Department

OBJECTIVES

The objective of the study was to determine if pain control was adequate despite our policy of limited opioid use.

METHODS

In this observational cohort study, we reviewed 300 consecutive patient charts from an internal medicine department. We extracted demographic data, as well as the patients' primary diagnosis, pain on admission, daily pain evaluations (numerical rating score [NRS]), and treatment. Significant pain was defined as a score of ≥3 on the NRS. We determined the incidence of pain and pain control and reviewed the charts of those with an NRS ≥3 for ≥3 days to determine the need for opioid therapy.

RESULTS

Of 1692 total hospitalization days in the 300 consecutive patients with a median age of 80 years (1st-3rd quartiles, 65-87 years) there were 204 days with complaints of pain (12.1%) and 149 days (8.8%) with reports of pain of ≥3 on the NRS. Overall, 28.3% (85 of 300) of the patients had significant pain during their hospitalization. Most of the pain, however, (80.0%, 68 of 85) was short-term (1-2 days) whether or not the patient received pain medication. Pain relief treatment in the hospital included opioids in 17 (5.7%, 95% confidence interval [CI] 3.5-8.9) and dipyrone in 36 (12%, 95% CI 8.8-16) of the 300 patients. Pain control was adequate in the seven patients with prolonged pain who did not receive opioids. There were only two patients discharged with prescriptions for opioids (0.7%, 95% CI 0.2-2.6).

CONCLUSIONS

Significant pain is common in patients hospitalized in an internal medicine department, but the pain is mostly short term and pain control is adequate despite the restricted use of opioid therapy during hospitalization.

Troponin Testing in Patients Without Chest Pain or Electrocardiographic Ischemic Changes

BACKGROUND

Although often recommended by experts, it is unclear if elevated troponin measurements have clinical utility in patients without chest pain or ischemic electrocardiographic changes.

OBJECTIVES

The objective of this study was to determine clinical utility, and downstream testing in patients with elevated troponin values but without chest pain or electrocardiographic changes.

METHODS

We selected all patients aged 30-100 years hospitalized in cardiology and internal medicine departments from July 1, 2013 until July 31, 2016. We chose a subgroup of 723 consecutive subjects with elevated troponin values for chart review to determine the proportion of patients without chest pain or ischemic electrocardiographic changes, and resultant differential treatment and downstream testing. Clinical utility was defined as coronary artery interventions or treatment of life-threatening arrhythmias.

RESULTS

Troponin measurements were sent in 52.5% of all hospitalized patients (16,519/31,448), and were elevated in 29.9% (4938/16,519). Nearly two-thirds of the patients reviewed had neither chest pain nor ischemic electrocardiographic changes (63.3% [458/723]), and the elevated troponin values did not result in coronary artery interventions or treatment of life-threatening arrhythmias. The elevated troponin values were the sole reason for hospitalization in 2.0% (n = 9), for cardiac monitoring in 6.1% (n = 28), for cardiac consultations in 11.1% (n = 51), and for left heart catheterization in 0.7% (n = 3) of the patients.

CONCLUSION

Most of the elevated troponin test results were in patients without chest pain or ischemic electrocardiographic changes, had no clinical utility, and resulted in downstream testing.

Treatment of febrile geriatric patients with suspected urinary tract infections in a hospital with high rates of ESBL producing bacteria: a cohort study

PURPOSE

To determine the consequences of treating febrile geriatric patients with a suspected urinary tract infection (UTI) with antibiotics that have high resistance rates due primarily to extended-spectrum β-lactamase (ESBL) producing bacteria.

METHODS

In this cohort study, we selected 257 consecutive hospitalised patients aged ≥70 years with a chief symptom of fever, possibly due to a UTI and initially treated with antibiotics with rates in our hospital of urinary culture resistance >20%. Patients with severe sepsis were excluded. The main outcomes measures were in vitro bacterial resistance to initial antibiotic therapy (BRIAT), response to therapy, hospitalisation days and mortality.

RESULTS

Urine cultures were positive in 64.2% (165 of 257) of the patients and BRIAT occurred in 28.0% (72 of 257). Response rates were 100% (93 of 93) in those with bacteria sensitive to initial antibiotic therapy, 95.7% (88 of 92) in the culture negative patients, and 66.7% (48 of 72) in those with BRIAT (p<0.001). There were no deaths due to deterioration during the initial treatment period because of BRIAT. In the patients with BRIAT, the median length of hospitalisation was 3 days longer than that in the other patients (7 and 4 days, respectively, p<0.001).

CONCLUSIONS

We conclude that initial broad spectrum antibiotic treatment could potentially lower the median length of hospitalisation by 3 days in many hospitalised geriatric patients without an extra-urinary tract source for their fever. This benefit needs to be balanced against the risk to the individual patient and to the general public of increasing bacterial resistance rates to broader spectrum antibiotics often held in reserve.

Auto-validation of complete blood counts in an outpatient's regional laboratory

BACKGROUND

The rate of auto-validation is dependent on the ability of the laboratory information system (LIS) to integrate historical data, on the frequency and methods for identifying analyzer errors, and on the criteria for reflex testing, including the need for peripheral smear review. The rate of auto-validation in outpatient laboratories, however, is unclear.

METHODS

We examined 45,925 consecutive complete blood count (CBC) test results (1 January, 2014-31 January, 2014) from patients aged 50±24 years. The LIS auto-validates all samples according to set criteria. Technicians validated test results when previous CBC test results were required to determine: 1) the need for peripheral slide review and/or sample rerun or 2) the need for reflex testing to detect autoimmune hemolytic anemia or β-thalassemia minor.

RESULTS

The auto-validation rates were 97.6% after rejecting results requiring validation to determine the need for a peripheral smear review and/or sample rerun. This decreased to 92.9% after including reflex testing to determine the reasons for normocytic and microcytic anemia. We estimated that auto-validation decreased the workload by 7.7-11.6 h per 3000 test results.

CONCLUSIONS

We conclude that very high auto-validation rates are possible in outpatient general laboratories, leading to conformity in the validation process and a considerable estimated savings in technician time. Further studies are needed in other settings.

Autovalidation rates in an outpatient coagulation laboratory

INTRODUCTION

To determine the rates of autovalidation in our outpatient coagulation laboratory.

METHODS

We retrospectively identified all coagulation tests analyzed during the month of January 2014 from our laboratory information system (LIS) (N = 16 116), from around 800 000 active members of Clalit Health Services (a health maintenance organization). The integrated system includes a single centrifugation of all collection tubes, analyzers that rerun or reflex tests according to the test results, and a laboratory information system that sends orders to the analyzer, autovalidates test results, and automatically sends critical value results to a list for immediate physician communication. Reasons for technician validation are tests rerun for confirmation or because of analyzer errors and test results that require reflex testing. All other test results are sent automatically to the laboratory information system without the need for technician review.

RESULTS

There were 362 test results with analyzer errors, 91 results rerun for confirmation (thrombophilia test results outside the reference interval), and 50 tests with mixing studies and reflex testing for factor XI activity levels (total = 3.1%, 503/16116), resulting in an autovalidation rate of 96.9% (95% confidence interval - 96.6-97.2%).

CONCLUSIONS

We conclude that an integrated system can result in a high autovalidation rate in a high-volume outpatient coagulation laboratory.

Measurement of post-void residual bladder volumes in hospitalized older adults

BACKGROUND

It is commonly recommended to catheterize or closely follow up patients with post-void residual volumes of 150 mL or more, but the frequency of such findings in geriatric hospitalized patients and the need for intervention are unclear.

METHODS

Post-void residual volumes were measured by ultrasound examination within 14 hours of admission in 464 patients aged 70 years or more who were hospitalized in a regional hospital general internal medicine department. Outcome variables included the need for an indwelling catheter and complications of urinary retention during the hospitalization.

RESULTS

Post-void residual volumes of ≥150 mL were common (23.9%; 111/464) and had the following distribution: 150 to 299 mL, 13.1% (61/464); 300 to 499 mL, 6.4% (30/464); and 500 mL or more, 6% (28/464). The rate of indwelling catheters was 3.2% (15/464). Results of post-void residual volumes did not predict the need for indwelling catheters in those without other criteria, although those with indications for indwelling catheters had a significantly higher frequency of post-void residual volumes ≥500 mL (P < .001) compared with those without such indications.

CONCLUSIONS

We conclude that urinary retention in hospitalized geriatric patients is common, but measurements of post-void residual volumes did not have definite clinical utility. However, the study had limited power to determine the benefits or potential harms of urinary catheterization for elevated post-void residual volumes.

Triple positive antiphospholipid antibody profile in outpatients with tests for lupus anticoagulants

BACKGROUND

A triple positive antiphospholipid (aPL) antibody profile [two positive serum IgG aPL antibodies along with one positive functional plasma lupus anticoagulant (LAC) test result] is associated with an increased risk for thrombosis, whereas patients with single positive test results may have little to no increased risk. The frequency of triple positivity in outpatients with various combinations of LAC test results is unclear.

METHODS

We extracted from our database all LAC test results [dilute Russell viper venom times (dRVVT) and silica clotting times (SCT)] that had concomitant serum IgG aPL testing [both serum anti β2-glycoprotein I (anti-β2GPI) and anti-cardiolipin (aCL) antibodies].

RESULTS

There were 3195 patients without a prolonged prothrombin time. Double antibody positivity was found in 1% (31/2955) of those with normal functional LAC test results, in 16.0% (31/81) of those with a positive dRVVT, in 12.7% (10/79) of those with a positive SCT, and in 56.3% (45/80) of those with both tests positive (p<0.001). A triple positive aPL antibody profile was found in 28.3% (68/240) of those with at least one positive LAC test result.

CONCLUSIONS

We conclude that 28% of patients with elevated LAC tests have a triple positive aPL antibody profile and patients with two positive LAC tests have a higher prevalence of a triple positive profile than do those with one positive LAC test result.

Functional capacity evaluation of work performance among individuals with pelvic injuries following motor vehicle accidents

OBJECTIVE

Pelvic injuries following motor vehicle accidents (MVA) cause disability and affect work capabilities. This study evaluated functional, self-report, and medical-based factors that could predict work capacity as was reflected in a functional capacity evaluation (FCE) among persons who sustained a pelvic injury. It was hypothesized that self-reported functional status and bio-demographic variables would predict work capacity.

PARTICIPANTS

Sixty-one community-dwelling adults previously hospitalized following a MVA induced pelvic injury.

METHODS

FCE for work performance was conducted using the Physical Work Performance Evaluation (PWPE). Additional data was collected through a demographics questionnaire and the Functional Status Questionnaire. All participants underwent an orthopedic medical examination of the hip and lower extremities.

RESULTS

Most participants self-reported that their work capacity post-injury were lower than their job required. PWPE scores indicated below-range functional performance. Regression models predicted 23% to 51% of PWPE subtests. Participants' self-report of functioning (instrumental activities of daily living and work) and bio-demographic variables (gender and age) were better predictors of PWPE scores than factors originating from the medical examination.

CONCLUSIONS

Results support the inclusion of FCE, in addition to self-report of functioning and medical examination, to evaluate work capacity among individuals' post-pelvic injury and interventions and discharge planning.

Criteria for reflex peripheral smear review in infants

Criteria for peripheral smear review are designed to include those samples with results outside the reference interval and can be more extreme based on what is considered to have clinical utility. However, we are unaware of previous studies that reported the distributions of various complete blood cell count (CBC) parameters in infants. In the following study we reviewed screening CBC results of 692 infants aged 9-15 months in order to determine the proportion of peripheral smear reviews recommended according to consensus criteria and that after adjusting for the observed distributions of the various parameters. According to consensus criteria the recommended reflex peripheral smear review rate was 39.7% (95% CI 36.1-43.4) whereas after adjustment for the observed distributions, the rate fell to 5.6% (95% CI 3.9-7.3) (p < 0.001). The major reasons for the difference in rates were the high proportion of infants with an absolute lymphocyte count > 7 × 10(9)/L (17.5%), the presence of a plus one blast flag (4.3%), and a large unstained cell count of ≥ 5% (26.2%) (equivalent to + 1 atypical flag). We found that international consensus criteria for reflex peripheral smear review results in a very high peripheral smear review rate in well infants, and might be inappropriate.

Anemia and estimated glomerular filtration rates

OBJECTIVE

To determine the relationship between the estimated glomerular filtration rate (eGFR) and the prevalence of anemia that has potential implications for reporting results of the eGFR.

METHODS

Serum creatinine and hemoglobin test results from 18,474 outpatients aged 50 years or older were reviewed. We calculated the eGFR using the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI) and the Modification of Diet in Renal Disease equation (MDRD) and determined the odds of anemia (according to the World Health Organization definition) at various eGFR levels, adjusted for age and gender.

RESULTS

The lowest proportion of anemia was observed in those with an eGFR of 80-89 mL/min per 1.73 m(2) and 90-99 mL/min per 1.73 m(2) (MDRD and CKD-EPI respectively), with an increasing prevalence of anemia in those with either an eGFR of 60-69 mL/min per 1.73 m(2) or 100-109 mL/min per 1.73 m(2) calculated by either equation (p<0.05) with a dose-response effect.

CONCLUSIONS

We found a U-shaped relationship between anemia and the eGFR, suggesting that values >60 mL per 1.73 m(2) should be reported. However, the clinical utility and potential side effects of reporting such values need to be determined. Also, these preliminary findings require confirmation by studies in other settings.

Automated evaluation of synovial and ascitic fluids with the Advia 2120 hematology analyzer

OBJECTIVES

The purpose of this study was to determine if the Advia 2120 hematology analyzer (Siemens Healthcare Diagnostics, Deerfield, IL) can accurately quantify both WBCs and the proportion of neutrophils from synovial and ascitic body fluids.

METHODS

We analyzed 60 samples on the Advia and compared the results with manual counts and smear reviews. We also assessed the effect of adding hyaluronidase to the samples. WBC counts and the proportion of neutrophils reported by the hematology analyzer were harmonized and highly correlated with manual counts and fluid smear reviews.

RESULTS

The addition of hyaluronidase to the synovial fluid consistently increased the WBC counts on both manual and automated analysis (P < .001).

CONCLUSIONS

We conclude that the Advia hematology analyzer can be used for WBC and neutrophil counting of cells in synovial and ascitic fluids. Hyaluronidase should be added before manual or automated counting of cells in synovial fluids.

Historical data decrease complete blood count reflex blood smear review rates without missing patients with acute leukaemia

INTRODUCTION

The availability of historical data decreases the rate of blood smear review rates in outpatients, but we are unaware of studies done at referral centres. In the following study, we determined the effect of historical data on the rates of peripheral blood smears over a 3-month period and then the detection rate of patients with acute leukaemia.

METHODS

All results of complete blood counts (CBCs) tested on three ADVIA 120 analyzers at the regional Rabin Medical Centre, Beilinson Campus over a 3-month period were accessed on a computerised laboratory information system. Over a 3-month period, we determined the proportion of total CBC and patients with criteria for a manual differential count and the actual number of peripheral blood smears done. Finally, we determined the proportion of 100 consecutive patients with acute leukaemia detected using our criteria that included limiting reflex testing according to historical data.

RESULTS

Over the 3-month period, there were 34,827 tests done in 12,785 patients. Without historical data, our smear rate would have been 24.5%, but with the availability of historical data, the blood smear review rate was 5.6%. The detection rate for cases of acute leukaemia was 100%.

CONCLUSIONS

We conclude that the availability of previous test results significantly reduces the need for blood smear review without missing any patients with acute leukaemia.