JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
GET YOUR FLU SHOT!
CHOOSING TELEMETRYWISELY: ASSESSING AWARENESS AND UTILIZATION OF AHA TELEMETRY PRACTICE STANDARDS
A. Butler, MD; K. Rizvi; R. Sinha; U. Jamal, MD Department of Medicine, Leonard J Chabert Medical Center, Houma, Louisiana
A. Brug; K. Hudson; R. Moore, MD; C. Chakraborti, MD Department of Internal Medicine, Tulane University Health Sciences Center, New Orleans
Introduction: Post viral pneumonias are a common component of influenza-related hospitalization and the presence of a superimposed bacterial infection can greatly increase both morbidity and mortality of influenza. Analysis of both the 1918 and 1957 influenza pandemics showed that two-thirds or more of the fatal cases were associated with secondary bacterial infection. Additionally, mortality from both influenza and secondary bacterial pneumonia is increased in individuals with comorbidities such as asthma, chronic obstructive pulmonary disease, diabetes or cardiovascular disease and immunosuppression. Case: A 53-year-old woman with a history of poorly controlled Type 2 Diabetes initially presented to Emergency department 1 week prior to admission complaining of myalgias, non- productive cough, fever and chills. At this time patient was diagnosed with influenza A and discharged home with supportive care. No Tamiflu was initiated, as symptoms began greater than 48 hours before diagnosis. The patient was admitted 1 week later with severe sepsis. CXR revealed multi- lobular PNA and severe sepsis protocol was initiated. The patient rapidly became severely hypotensive (80s/50s) with lactic acid exceeding >6, despite being aggressively fluid resuscitated; she was started on pressors and intubated. Bedside echo revealed EF approx 20-25% with large anterior defect, with troponin at >30. She became more acidotic, requiring additional pressors (dobutamine and vasopressin) along with high dose steroids to maintain adequate BP. The patient eventually went into PEA, where ROSC was achieved after 40 minutes. After coding, the patient still required pressor support to maintain BP and a decision to withdraw care was made. Final respiratory culture data was consistent with MRSA. PCR for influenza B returned positive. Discussion: This case occurred in mid-September 2017 and was the first confirmed fatality of the 2017-2018 influenza season. As a direct result, the CDC updated its influenza recommendations to the state of Louisiana and to the nation as a whole. Updates included recommending that vaccination campaigns begin immediately, rather than waiting for October. Additionally, the advisement was made to treat all hospitalized and high-risk patient with suspected or confirmed influenza with antiviral medications regardless of onset of symptoms and without waiting for confirmatory testing.
Background: The American Board of Internal Medicine Foundation’s campaign, Choosing Wisely, includes five recommendations to reduce unnecessary healthcare spending. One of these is "Do not order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation." The 2004 AHA Practice Standards for Electrocardiographic Monitoring reliably predict cardiac events and change patient management and thus, have the potential to act as such a protocol. However, a better understanding of current decision-making and usage of these guidelines is needed to assess whether they are practical. Methods: A survey was distributed to Internal Medicine attendings, residents, and interns, at Tulane University Medical Center. The survey included 14 patient scenarios based on the 2004 AHA Practice Standards that required respondents to indicate whether they would “absolutely monitor”, “consider monitoring”, or “not monitor” each patient on telemetry. The survey also assessed awareness and use of the AHA Practice Standards, institutional guidelines, and the extent to which each physician relied on gestalt when deciding to use telemetry. Results: There were 55 respondents-23 interns, 16 residents, and 16 attendings. Physicians decided to use telemetry in accordance with AHA guidelines 54% of the time. Proper utilization of telemetry was not statistically correlated with level of training (p=0.569) and awareness of the AHA guidelines was not predictive of compliance (p = 0.414). The proportion of physicians aware of the AHA guidelines differs significantly based on level of training (Fischer’s exact p=.021). There is no significant difference by level of training in those who agree that they utilize the AHA guidelines or their institution's guidelines (AHA p=.104, 19.6% overall; Institutional p=.278, 14.2% overall). Nearly all respondents rely on “previous clinical experience and physician gestalt”with no statistical significance when stratified by level of training (p=1.0). Conclusion: Awareness of 2004 AHA Practice Standards for Electrocardiographic Monitoring increases with higher levels of training. However, utilization of the guidelines does not improve accordingly and clinical experience and gestalt dominate the decision to use telemetry. Ultimately, these decisions do not reliably alignwith the AHA guidelines, suggesting the guidelines may not be the optimal tool for implementing the Choosing Wisely campaign recommendations.
66 J La State Med Soc VOL 170 MARCH/APRIL 2018
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