A Simple Checklist for Central Lines Saves Lives and Money

Dr. Joseph Esherick Monthly Blog - June 2011

Safety checklists have been adopted by numerous industries to prevent errors and save lives.  Checklists have been used for decades by industries as diverse as the aviation industry, construction companies, and professional chefs to prevent mistakes.  In medicine, checklists have been used in the operating room to prevent surgical errors and for central line placement to prevent catheter-related blood stream infections (CRBSIs).

The pioneer of safety checklists in medicine is Dr. Peter Provonost who spearheaded the Michigan Keystone ICU Project that ended in 2006[1].   The checklist used for central venous catheter placement is simple and involves only five key steps that are rooted in evidence-based medicine:  wash your hands; cleanse the insertion site thoroughly with chlorhexidine; maximal barrier precautions (wear a mask covering the nose and mouth, a cap covering all your hair, sterile gown, sterile gloves and use a wide sterile drape over the patient); a nurse or observer is empowered to stop the procedure if there is any break in sterile technique; and there is a daily review of central line necessity.

The checklist summarizes all of the vital elements required to minimize the risk of CRBSIs. However, implementation requires intensive staff education and buy-in as well as a system-wide culture change[2].   Nurses must become emboldened to stop a procedure when doctors don’t wash their hands or thoroughly cleanse the insertion site with chlorhexidine.  In addition, healthcare providers must believe that CRBSIs are preventable and no longer inevitable.

In the Michigan ICU Collaborative, Dr. Provonost introduced this safety checklist and changed the culture within the Intensive Care Units of over 100 hospitals in Michigan.  Over an 18 month span, the rate of CRBSIs decreased from 7.7 infections per 1,000 catheter days to 1.4 infections per 1,000 catheter days.  This project was estimated to save 1,500 lives and $175 million[3].

How important is this area?  In the United States, roughly five million central lines are placed each year.  CRBSIs are reported to occur at a frequency of between 3-8% depending on the region studied.  Approximately 80,000 CRBSIs occur each year in the U.S. which either cause or contribute to 28,000 deaths per year.  The estimated cost of treatment of a single CRBSI is approximately $45,000 which equates to an annual cost of $2.3 billion to treat these infections in our country[4].   If this checklist can be successfully implemented nationwide and lead to an identical reduction in CRBSIs as was seen in the Keystone Project, the intervention would save 23,000 lives and save our country roughly $1.65 billion each year.

This proven program will now be rolled out in at least 28 states in the United States with the goal of reducing CRBSIs by 75% within 3 years.  This is an ambitious project that is being supported by the US Health and Human Services Secretary Kathleen Sebelius, but is well worth the effort.[3]  None of these interventions is particularly new and it is unclear which of the interventions is of the most benefit.  What is known, though, is that compliance with the entire bundle and a sustained change in the culture of a hospital to a “culture of safety” will definitely lead to a reduced incidence of CRBSIs and will ultimately reduce mortality and healthcare costs.

---

  
Joseph Esherick, MD, FAAFP is the Associate Director of Medicine and the Medical ICU Director at the Ventura County Medical Center in Ventura, California.  He is also an Associate Clinical Professor of Family Medicine at The David Geffen School of Medicine at UCLA. He received his medical degree from Yale University School of Medicine, New Haven, Connecticut, and completed a family practice residency at the Ventura County Medical Center, Ventura, California. He is board certified in family medicine and the author of the Tarascon Primary Care Pocketbook and the Tarascon Hospital Medicine Pocketbook. He instructs the Hospitalist Procedures course for the National Procedures Institute and is an editorial board member for Tarascon Publishing and for Elsevier’s First Consult.

 Dr. Esherick is the author of some of Tarascon Publishing's best-selling titles including:
the Just Published Tarascon Medical Procedures Pocketbook, Tarascon Hospital Medicine Pocketbook and Tarascon Primary Care Pocketbook.  Both titles are available in print and mobile (iPhone, Android and Blackberry).

---

[1] Pronovost P et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med. 2006; 355: 2725-2732.

[2] Zingg W et al. Impact of a Prevention Strategy Targeting Hand Hygiene and Catheter Care on the Incidence of Catheter-related Bloodstream Infection. Crit Care Med. 2009; 37: 2167-2173.

[3] Laurance J. Peter Pronovost: champion of checklists in critical care. Lancet. 2009; 374: 443.

[4] Frasca D et al. Prevention of Central Venous Catheter-related Infection in the Intensive Care Unit. Critical Care. 2010; 14: 212-219.

Global Health Blog

Dr. Amit Chandra & Dr. Matthew Dacso Monthly Blog - June 2011

Greetings from Gaborone, Botswana! 

We, the editors of the Tarascon Global Health Pocketbook, decided to begin our contribution to this blog with a joint introduction and overview of our careers and background in Global Health.  Between the two of us, we have had experiences and collaborated on health research over the past decade in the USA, Canada, Argentina, Peru, India, and Botswana.  We both currently live in Gaborone, Botswana, in Southern Africa.  A middle income-country with a wealth of natural resources, Botswana has been devastated by the global HIV epidemic, and has one of the highest rates of HIV prevalence in the world (24%).  Here, we are working with local partners and institutions to develop the country’s first medical school and build local capacity in HIV primary care.

Prior to our medical training, we both gained an academic background in Development Studies, a multidisciplinary approach to issues of the developing world.  We took particular interest in the work of Nobel Laureate Amartya Sen, whose “Development as Freedom” concept focused on the public sector and public institutions not as bureaucratic regulators, but as guarantors of individual capacities: health, literacy, and democracy.

As soon as we began medical school, we each embarked on our own “global health experiences,” learning the hard way about the pitfalls of undertaking health projects prior to the completion of one’s training.  The Tarascon Global Health Pocketbook was born out of a series of conversations and debates concerning the nature and ethics of our own and others’ global health experiences, and an attempt to reconcile international health work with the core principles of development studies: capacity building, human capital, political economy, institutions, participation, and partnership.

The Tarascon Global Health Pocketbook was designed to be used by medical and public health practitioners at all levels who plan to undertake global health experiences.  It is a clinical practice manual providing overviews of common global health challenges: e.g. water borne illness, HIV, meningitis, sepsis.  It also provides regional health overviews and country profiles that bring together key indicators relevant to global health practice.

Over the coming months, we plan to continue posting global health posts on this blog, with a particular focus on our combined areas of interest, our work in Botswana, and our research projects:

Global Health Education- How should global health rotations for North American medical students and residents be organized to ensure mutual benefit, adequate supervision, and safety?

Global Health governance- What standards govern the work of organizations engaging in global health (e.g. academic partnerships, pharmaceutical companies, aid organizations)?

ICT tools in Global Health- Information Communication Technology has the potential to revolutionize health care not only in wealthy countries, but in developing ones as well.  Mobile phones in particular, given their widespread use in many middle-income countries, have numerous health applications that are currently in the pilot phase.

_______________________________________________________________________________

Amit Chandra, MD, MSc is an Emergency Physician living in Gaborone, Botswana.  He is a lecturer at the University of Botswana School of Medicine, and a founding faculty member of Botswana's first emergency medicine residency program.  Dr. Chandra studied economics at McGill University in Montréal and development studies at the London School of Economics before attending medical school at the Eastern Virginia Medical School.  His current research projects involve global health education, HIV emergencies, aviation emergencies, and trauma and road safety in Southern Africa.  In 2010, he co-edited the Tarascon Global Health Pocketbook, featuring chapters on topical and regional issues in Global Health.  He also serves as a reviewer for the Bulletin of the WHO and the African Journal of Emergency Medicine.

Matthew Dacso, MD, MSc is a general internist from Houston, Texas.  He studied music at McGill University, international development at the University of London School of Oriental and African Studies, and medicine at the University of Texas Medical Branch in Galveston before completing residency at Brown University in Providence, Rhode Island.  He has worked in health care in Argentina, Peru, the Dominican Republic, Mexico, and Botswana.  His current research focuses on non-communicable diseases in HIV, traditional medicine, and global health medical education.  He continues his work in community health and development as an HIV outreach specialist for the Botswana-UPenn Partnership and is an active faculty member of the Department of Internal Medicine at the University of Botswana, both based in Gaborone, Botswana.  In 2010, he co-edited the Tarascon Global Health Pocketbook.

Pre-Procedural Statins Reduce the Incidence of Peri-procedural Cardiac Events

Dr. Joseph Esherick Monthly Blog - May 2011

Initiation of statins during the acute period has been shown to be beneficial during an acute coronary syndrome and immediately following an ischemic stroke. [1,2,3]  It is believed that statins, HMG-CoA reductase inhibitors, have pleiotropic properties that have anti-inflammatory effects, improve endothelial function and inhibit the body’s thrombogenic response.  The properties are in addition to the lipid lowering effects of statins.  These pleiotropic effects are felt to be the principal mechanism by which statins decrease recurrent cardiovascular and cerebrovascular events when started acutely during an acute coronary syndrome or immediately after an ischemic stroke.  Statins have also been shown in two randomized controlled trials to decrease the incidence of peri-procedural myocardial infarction if started soon before percutaneous coronary intervention or before major vascular surgery. [4,5] 

It is with this background that Winchester et al. performed a meta-analysis of randomized trials to determine whether the pre-procedural initiation of statins can reduce peri-procedural myocardial infarctions. [6]  Studies were selected that compared patients scheduled to undergo an invasive procedure which randomized patients to statin therapy versus control.  Trials were excluded if multiple interventions were performed.  Twenty one randomized trials with a total of 4,805 patients were included in the meta-analysis.  A statin was initiated between 1 – 30 days prior to the procedure.  The primary outcome was post-procedural nonfatal myocardial infarction.  Secondary outcomes were mortality, need for revascularization, or atrial fibrillation.  The primary procedures included in these trials were percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or noncardiac surgery.

The results of the meta-analysis are that pre-procedural initiation of statins significantly reduces the incidence of MI after PCI or noncardiac surgery.  Statins did not lead to a mortality reduction for any procedure and did not reduce the incidence of post-operative MI after a CABG.  Statins significantly reduced the risk of an MI after PCI and after major noncardiac surgery (relative risk 0.57, 95% CI 0.46-0.7; p=0.004).  The PCI trials initiated a statin 1-7 days prior to the procedure, but the trials involving noncardiac surgery started the statin 30 days prior to the operation.

The meta-analysis did have some significant drawbacks.  First, five different statins were used in the different trials and multiple different dosages were studied.  Second, the optimal duration of therapy is unclear.  The follow-up duration ranged from 1 day to 6 months.

This study did show a consistent benefit of pre-procedural initiation of a statin prior to PCI or major nonvascular surgery.  If possible, the statin should be initiated at least 1 week prior to PCI and at least 30 days prior to major nonvascular surgery.  Statins should be continued for at least 30 days after major nonvascular surgery and should be continued indefinitely for patients found to have significant coronary artery disease at the time of cardiac catheterization.  The lack of proven benefit prior to CABG may be related to the small sample size in these trials or the relatively lose dose of statin used (atorvastatin 20 mg/day or simvastatin 20 mg/day).  More data are needed for CABG before any definitive recommendation is made.

---

  
Joseph Esherick, MD, FAAFP is the Associate Director of Medicine and the Medical ICU Director at the Ventura County Medical Center in Ventura, California.  He is also an Associate Clinical Professor of Family Medicine at The David Geffen School of Medicine at UCLA. He received his medical degree from Yale University School of Medicine, New Haven, Connecticut, and completed a family practice residency at the Ventura County Medical Center, Ventura, California. He is board certified in family medicine and the author of the Tarascon Primary Care Pocketbook and the Tarascon Hospital Medicine Pocketbook. He instructs the Hospitalist Procedures course for the National Procedures Institute and is an editorial board member for Tarascon Publishing and for Elsevier’s First Consult.

Dr. Esherick is the author of some of Tarascon Publishing's best-selling titles including:
Tarascon Hospital Medicine Pocketbook and Tarascon Primary Care Pocketbook.  Both titles are available in print and mobile (iPhone, Android and Blackberry).

---

[1] Bavry AA, Mood GR, Kumbhani DJ, Borek PP, Askari AT, Bhatt DL. Long-term benefit of statin therapy initiated during hospitalization for an acute coronary syndrome: a systematic review of randomized trials. Am J Cardiovasc Drugs 2007; 7: 135– 41.
 
[2] Hulten E, Jackson JL, Douglas K, George S, Villines TC. The effect of early, intensive statin therapy on acute coronary syndrome: a meta-analysis of randomized controlled trials. Arch Intern Med 2006; 166: 1814 –21.
 
[3] Amarenco P, Bogousslavsky J, Callahan A 3rd, Goldstein LB, Hennerici M, Rudolph AE, Sillesen H, Simunovic L, Szarek M, Welch KM, Zivin JA; Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators.  High-dose atorvastatin after stroke or transient ischemic attack.  N Engl J Med. 2006; 355(6): 549-59.
 
[4] Pasceri V, Patti G, Nusca A, et al. Randomized trial of atorvastatin for reduction of myocardial damage during coronary intervention: results from the ARMYDA (Atorvastatin for Reduction of MYocardial
Damage during Angioplasty) study. Circulation 2004; 110: 674–8.
 
[5] Schouten O, Boersma E, Hoeks SE, et al. Fluvastatin and perioperative events in patients undergoing vascular surgery. N Engl J Med 2009; 361: 980 –9.
 
[6] Winchester DE, Wen X, Xie L, and Bavry A. Evidence of Pre-Procedural Statin Therapy: A Meta-Analysis of Randomized Trials.  J. Am. Coll. Cardiol. 2010; 56; 1099-1109.

Jones & Bartlett Learning is Proud to Partner with NLA

Treatment & Management of Acute Coronary Syndrome

Dr. Joseph Esherick Monthly Blog - April 2011

The leading cause of death in the United States is cardiovascular mortality.  Therefore, the early identification and appropriate management of acute coronary syndrome is essential for all hospital-based physicians.  The American College of Cardiology Foundation and the American Heart Association have recently updated their practice guidelines on the management of patients with unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI)[1].  

This blog will focus on the primary changes in the management of non-ST-elevation acute coronary syndrome.  The Level 1 recommendations are that patients with definite UA/NSTEMI at medium to high risk should receive 325 mg of aspirin and a second antiplatelet agent on presentation.  Dual antiplatelets should be given regardless of whether an invasive or conservative strategy is chosen.  The second antiplatelet agent could be either a loading dose of clopidogrel, prasugrel, or a GP IIb/IIIa inhibitor (preferably eptifibatide or tirofiban).  The major change in the recommendations is that dual antiplatelet therapy is now routinely recommended upstream of percutaneous coronary intervention (PCI).  In patients undergoing PCI, both aspirin and a thienopyridine, clopidogrel or prasugrel, should be continued for at least 12 months.  For those treated conservatively, dual antiplatelet therapy should continue for at least 1 month and ideally for 1 year.

Certain aspects of antiplatelet therapy that remains undefined in UA/NSTEMI include the optimal loading dose of clopidogrel and the optimal thienopyridine to use.  It remains unclear whether patients should receive a clopidogrel loading dose of 300 mg or 600 mg.  In addition, although there are preliminary reports that have demonstrated improved outcomes with prasugrel compared with clopidogrel (primarily a reduction in nonfatal myocardial infarctions), the bleeding risk is higher with prasugrel.  Therefore, at this point either thienopyridine may be used as the second antiplatelet agent.

It is often difficult to decide who should be managed via in early invasive approach versus a conservative approach.  Patients who qualify for an early invasive approach (within 12-24 hours of presentation) include those with refractory angina or hemodynamic or electrical instability, and high-risk patients who have an elevated risk for clinical events.

Patients who are treated with a conservative approach should follow additional guidelines with regards to diagnostic and therapeutic management.  A cardiac catheterization is indicated if they develop recurrent chest pain, heart failure, or arrhythmias, or if a myocardial perfusion scan prior to discharge reveals evidence of occult cardiac ischemia.  In addition to dual antiplatelet therapy, antithrombotic therapy should be initiated upon presentation.  Antithrombotic therapy could be in the form of an unfractionated heparin infusion or with therapeutic doses of a low-molecular-weight heparin (LMWH) or fondaparinux.  Antithrombotic therapy should be continued for the duration of the hospitalization, up to 8 days.  For those with a history of GI bleeding, concomitant administration of acid-suppressing medications (e.g., H2-receptor blockers or proton pump inhibitors) should be used.  It is still unclear whether certain proton pump inhibitors (PPIs) decrease the antiplatelet efficacy of clopidogrel, but PPIs do not inhibit the efficacy of prasugrel.  Also, H2-receptor blockers do not affect the antiplatelet effect of either clopidogrel or prasugrel.

Additional therapies that are recommended during the period of hospitalization include the following.  Beta-blocker therapy titrated to a resting heart rate of 55-65 beats/minute and high-dose statins (e.g., atorvastatin 80 mg/day) are routine interventions.  In addition, patients with diabetes should have their blood glucose levels maintained less than 180 mg/dL.  Patients with chronic kidney disease should receive adequate hydration prior to coronary angiography and the amount of contrast used during angiography should be minimized.  The evidence was not sufficient to recommend any specific type of intravenous fluid for hydration (i.e., sodium bicarbonate versus normal saline) or whether N-acetylcysteine administration as adjunctive therapy to hydration was beneficial.

 

---

Joseph Esherick, M.D., FAAFP is the Associate Director of Medicine and the Medical ICU Director at the Ventura County Medical Center in Ventura, California.  He is also an Associate Clinical Professor of Family Medicine at The David Geffen School of Medicine at UCLA. He received his medical degree from Yale University School of Medicine, New Haven, Connecticut, and completed a family practice residency at the Ventura County Medical Center, Ventura, California. He is board certified in family medicine and the author of the Tarascon Primary Care Pocketbook and the Tarascon Hospital Medicine Pocketbook. He instructs the Hospitalist Procedures course for the National Procedures Institute and is an editorial board member for Tarascon Publishing and for Elsevier’s First Consult.

Dr. Esherick is the author of some of Tarascon Publishing's best-selling titles including:
Tarascon Hospital Medicine Pocketbook and Tarascon Primary Care Pocketbook.  Both titles are available in print and mobile (iPhone, Android and Blackberry).

---

[1] Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE Jr, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP. 2011 ACCF/AHA focused update of the guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction (updating the 2007 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011; 57: xxx–xxx (in press).