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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_407"
                     title="ICU Catheter Infections Can Be Virtually Eliminated (CME/CE)"
                     score="0.012"
                     href="http://www.medpagetoday.com/CriticalCare/InfectionControl/tb/18308?impressionId=1265761240758"
                     
      Catheter-related infections aren&apos;t inevitable in the ICU, according to a quality initiative that maintained rates at nearly zero for three years in Michigan hospitals.&lt;br&gt;
&lt;br&gt;The maintenance phase, after initial implementation of low-tech measures such as handwashing and removal of unneeded catheters, saw no rebound in catheter-related infections, Peter J. Pronovost, MD, PhD, of Johns Hopkins, and colleagues reported online in &lt;em&gt;BMJ&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;The first 18 months of their &lt;a href=&quot;http://www.medpagetoday.com/InfectiousDisease/GeneralInfectiousDisease/4771&quot; mce_href=&quot;http://www.medpagetoday.com/InfectiousDisease/GeneralInfectiousDisease/4771&quot; target=&quot;_blank&quot;&gt;Keystone ICU initiative&lt;/a&gt; dropped catheter-related interventions from a mean of 7.7 and median of 2.2 per 1,000 catheter days down to 1.3 and 0, respectively.&lt;br&gt;
&lt;br&gt;At the 36 month mark, infection rates remained almost nil, at a mean of 1.1 and median of 0 per 1,000 catheter days.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;&quot;For the most part, hospitals view these infections as inevitable, as the cost of doing business, that patients are too sick, that these can&apos;t be prevented,&quot; Pronovost told &lt;em&gt;MedPage Today&lt;/em&gt;. &quot;That&apos;s just not true.&quot;&lt;/p&gt;
&lt;p&gt;Catheter-related infections are the number one cause of preventable death in hospitals and ICUs, ahead of even ventilator-related pneumonia, he noted.&lt;/p&gt;
&lt;p&gt;The changes seen at the 90 Michigan ICUs that stayed with the catheter-related infection initiative were impressive, representing one of the largest and longest improvements the field has seen.&lt;/p&gt;
&lt;p&gt;Often, quality initiatives fail on durability after the study funding and resources disappear, and hospitals are left on their own, Pronovost noted.&lt;/p&gt;
&lt;p&gt;&quot;If you push you might get some effect, but then you stop pushing  --  in other words the external control goes away  --  and the performance goes right back down,&quot; he said in an interview. &quot;It can&apos;t just be the stick that drives it.&quot;&lt;/p&gt;
&lt;p&gt;The intervention started with 103 ICUs that implemented strategies to reduce rates of catheter-related bloodstream infections rates over 18 months, with measurement and feedback of infection rates.&lt;/p&gt;
&lt;p&gt;The strategies aimed at improving execution of five evidence-based recommendations, as follows: &lt;ul&gt; &lt;li&gt;Hand washing before insertion of the catheter&lt;/li&gt; &lt;li&gt;Using gowns and full barrier precautions at catheter insertion&lt;/li&gt; &lt;li&gt;Cleaning the skin with chlorhexidine before catheter insertion&lt;/li&gt; &lt;li&gt;Avoiding the femoral site when possible&lt;/li&gt; &lt;li&gt;Removing unnecessary catheters&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Then, over the subsequent 18-month maintenance period, ICU teams were instructed to integrate this intervention into staff orientation, to collect monthly data from hospital infection control staff, and to report infection rates to physicians and others.&lt;/p&gt;
&lt;p&gt;Along with the sustained reduction in overall catheter-related infections, the researchers found a prolonged reduction in bloodstream infections that was significant during all study periods, compared to baseline.&lt;/p&gt;
&lt;p&gt;Rates decreased from a mean of 7.7 and median 2.7 of per 1,000 catheter days at baseline to 1.3 and 0, respectively, at 16 to 18 months after implementation. They remained at 1.1 and 0 at months 34 to 36 (-1% versus 18 months, 95% CI -9% to +7%).&lt;/p&gt;
&lt;p&gt;ICU teams interviewed attributed the continuously low rates to five factors: &lt;ul&gt; &lt;li&gt;Continued feedback on infection data&lt;/li&gt; &lt;li&gt;Improvements in safety culture as part of the project&lt;/li&gt; &lt;li&gt;An &quot;unremitting belief in the preventability of bloodstream infections&quot;&lt;/li&gt; &lt;li&gt;Involvement of senior leaders&lt;/li&gt; &lt;li&gt;A noncompetitive, shared goal to reduce infection rates throughout the state&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Of these, Pronovost called culture change in the ICUs the key factor to sustainability, although the researchers cautioned that which aspects contributed were not formally evaluated.&lt;/p&gt;
&lt;p&gt;They said they could not determine the impact incentive payments from Blue Cross Blue Shield of Michigan to hospitals that continued their participation  --  payments that were based on performance thresholds in subsequent years.&lt;/p&gt;
&lt;p&gt;Pronovost&apos;s team is now working to implement the quality initiative state-by-state nationwide, supported by the Agency for Healthcare Research and Technology.&lt;/p&gt;
&lt;p&gt;&quot;It seems absurd that this wouldn&apos;t be in every hospital in the country,&quot; he said in an interview. &quot;It&apos;s worked on a large scale, it&apos;s exceedingly cheap, there&apos;s no fancy technology.&quot;&lt;/p&gt;
&lt;p&gt;Success isn&apos;t only for community hospitals, Pronovost emphasized.&lt;/p&gt;
&lt;p&gt;Large, often academic, medical centers frequently express the conviction that their sicker, more complex ICU population wouldn&apos;t produce the same results, that their infections truly are inevitable, he said.&lt;/p&gt;
&lt;p&gt;&quot;To them I say, Not so,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;. &quot;We have shown at Johns Hopkins, at the University of Michigan, at Pittsburgh, using a similar but different approach, at Tufts  --  many large academic medical centers have had dramatic reductions of these infections.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The project was supported, for the period from October 2003 to September 2005, by the Agency for Healthcare Research and Quality and the Michigan Health &amp;amp; Hospital Association.&lt;/p&gt;&lt;p&gt;Pronovost and a co-author reported receiving received lecture fees from various healthcare organizations and grant support from the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, the National Patient Safety Agency, and the World Health Organization to study and improve quality of care, including catheter-related bloodstream infections.&lt;/p&gt;&lt;p&gt;Co-authors reported conflicts of interest with government agencies, Cubist, Astellas, Merck, Forrest, Cadence, the Robert Wood Johnson Foundation, Lilly, Edward Life Sciences, and Sage.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_329"
                     title="Nixing Routine ICU Sedation Improves Outcomes (CME/CE)"
                     score="0.006"
                     href="http://www.medpagetoday.com/CriticalCare/Intensivists/tb/18199?impressionId=1265761240758"
                     
      A protocol of no sedation in the ICU may get patients off the ventilator and back home sooner, Danish researchers found.&lt;br&gt;
&lt;br&gt;Unsedated patients spent 4.2 fewer days on mechanical ventilators than those treated under a more conventional protocol for daily interruption of sedation (mean 13.8 versus 9.6 days without ventilation, &lt;em&gt;P&lt;/em&gt;=0.0191) in a randomized trial led by Thomas Str&amp;#248;m, MD, of Odense University Hospital.&lt;br&gt;
&lt;br&gt;Length of stay in the ICU and in the hospital were significantly shorter as well, the researchers reported in the Feb. 6 issue of &lt;em&gt;The Lancet&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The strategy appeared safe, with no increase in accidental extubation or other complications, Str&amp;#248;m&apos;s group said.&lt;/p&gt;
&lt;p&gt;Although simpler than daily interruption of sedation, a no-sedation protocol could mean extra work for ICU staff, according to an accompanying editorial.&lt;/p&gt;
&lt;p&gt;Laurent Brochard, MD, of the Centre Hospitalier Albert Chenevier&amp;#8211;Henri Mondor in Cr&amp;#233;teil, France, wrote that the protocol would call for &quot;more frequent individual assessment of the patient&apos;s pain, fear, anxiety, agitation, or confusion, and adaption to the ventilator.&quot;&lt;/p&gt;
&lt;p&gt;It would also likely impose an increased workload in reassurance and patient mobilization, he said. Still, he called the results &quot;impressive and promising.&quot;&lt;/p&gt;
&lt;p&gt;Sedation is often overused in the ICU, particularly since drugs can accumulate in critically ill patients, Brochard asserted, and daily interruption of sedation was a major breakthrough in patient care because it was shown to &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/ATS/5713&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/ATS/5713&quot; target=&quot;_blank&quot;&gt;reduce duration of ventilation&lt;/a&gt;.&lt;/p&gt;
&lt;p&gt;Other benefits of the current study included reductions in &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/SCCM/8240&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/SCCM/8240&quot; target=&quot;_blank&quot;&gt;post-traumatic stress disorder&lt;/a&gt; and &lt;a href=&quot;http://www.medpagetoday.com/EmergencyMedicine/EmergencyMedicine/7931&quot; mce_href=&quot;http://www.medpagetoday.com/EmergencyMedicine/EmergencyMedicine/7931&quot; target=&quot;_blank&quot;&gt;complications&lt;/a&gt; such as ventilator-associated pneumonia, Str&amp;#248;m and colleagues added.&lt;/p&gt;
&lt;p&gt;In an effort to further reduce the negative effects of ICU sedation, their hospital adopted a routine protocol of no sedation for intubated medical and surgical ICU patients receiving mechanical ventilation.&lt;/p&gt;
&lt;p&gt;Given the lack of randomized data on the benefits of this strategy, the researchers randomized 140 critically ill adults expected to need more than 24 hours of ventilation to unblinded treatment without sedation or with an infusion of propofol (Diprivan) for 48 hours, then an infusion of midazolam (Versed) as needed for sedation with daily interruption until awake.&lt;/p&gt;
&lt;p&gt;Both groups got bolus doses of morphine (2.5 or 5 mg) as needed and daily mobilization to a chair if possible.&lt;/p&gt;
&lt;p&gt;Along with the reduction in ventilated days, the researchers found that patients on the no-sedation protocol left the ICU 9.7 days sooner on average and were discharged from the hospital 24 days earlier than those routinely sedated.&lt;/p&gt;
&lt;p&gt;After adjustment for baseline variables, sedation remained significantly associated with increased ICU stay (HR 1.86, 95% CI 1.05 to 3.23).&lt;/p&gt;
&lt;p&gt;The effect on hospital stay duration, though, was limited to the first 30 days (HR 3.57 for sedation, 95% CI 1.52 to 9.09).&lt;/p&gt;
&lt;p&gt;For days 31 to 90, sedation protocol had no impact (&lt;em&gt;P&lt;/em&gt;=0.54), likely because other factors, such as comorbidities, were more important when patients couldn&apos;t be weaned from ventilation, the researchers said.&lt;/p&gt;
&lt;p&gt;Complications were similar between no-sedation and sedation protocol groups as follows: &lt;ul&gt; &lt;li&gt;Accidental removal of endotracheal tube (seven versus six cases, &lt;em&gt;P&lt;/em&gt;=0.69)&lt;/li&gt; &lt;li&gt;Need for CT or MRI brain scans (five versus eight cases, &lt;em&gt;P&lt;/em&gt;=0.43)&lt;/li&gt; &lt;li&gt;Ventilator-associated pneumonia (six versus seven cases, &lt;em&gt;P&lt;/em&gt;=0.85)&lt;/li&gt; &lt;li&gt;Need for reintubation within 24 hours (seven versus 11 cases, &lt;em&gt;P&lt;/em&gt;=0.37)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Mortality in the ICU tended to be higher with sedation (38% versus 22%, P=0.06), but there was no significant difference in overall inhospital mortality between the groups (47% with sedation versus 36% without, &lt;em&gt;P&lt;/em&gt;=0.27).&lt;/p&gt;
&lt;p&gt;Overall, 18% of patients in the no-sedation group couldn&apos;t tolerate it and had to receive continuous sedation on more than two occasions, typically to permit sufficient oxygenation in severe acute respiratory distress syndrome.&lt;/p&gt;
&lt;p&gt;The one negative impact of the no-sedation strategy appeared to be an increase in agitated delirium (20% versus 7%, &lt;em&gt;P&lt;/em&gt;=0.04) resulting in more frequent use of haloperidol (Haldol, &lt;em&gt;P&lt;/em&gt;=0.0100).&lt;/p&gt;
&lt;p&gt;Morphine, which does have a sedative effect, was used at a low level in both groups without a significant difference.&lt;/p&gt;
&lt;p&gt;But it&apos;s likely that delirium went undetected in some sedation group patients, given the difficulty of assessing the condition even when patients are awakened routinely, Str&amp;#248;m&apos;s group said. Assessing confusion rather than hyperactive delirium might be a better strategy, they suggested.&lt;/p&gt;
&lt;p&gt;They said they plan to follow patients at one year to assess long-term psychological effects.&lt;/p&gt;
&lt;p&gt;The researchers and editorialist agreed that further confirmation of these results are needed in multicenter research to determine whether the strategy is generalizable.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the Danish Society of Anesthesiology and Intensive Care Medicine, the Fund of Danielsen, the Fund of Kirsten Jensa la Cour, and the Fund of Holger og Ruth Hess.&lt;/p&gt;&lt;p&gt;The researchers reported no conflicts of interest.&lt;/p&gt;&lt;p&gt;Brochard reported that his research laboratory has received research grants from several ventilator companies (Maquet, Dr&amp;#228;ger, Philips Respironics, General Electric) but no personal relationship to disclose for the use of sedation in intensive care.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_301"
                     title="Tight Glucose Control Fails in Septic Shock (CME/CE)"
                     score="0.004"
                     href="http://www.medpagetoday.com/CriticalCare/Sepsis/tb/18160?impressionId=1265761240758"
                     
      Septic shock patients treated with a corticosteroid get no survival advantage from tight glucose control or addition of a second corticosteroid to provide more mineralocorticoid activity, according to results of a randomized trial.&lt;br&gt;
&lt;br&gt;Aiming for normoglycemia at 80 to 110 mg/dL rather than the standard 150 mg/dL had no impact on inhospital mortality rates (45.9% versus 42.9%, &lt;em&gt;P&lt;/em&gt;=0.50), Djillali Annane, MD, of H&amp;#244;pital Raymond Poincar&amp;#233; in Garches, France, and colleagues found.&lt;br&gt;
&lt;br&gt;Inhospital mortality was likewise similar whether patients got hydrocortisone (Solu-Cortef) alone or with the addition of fludrocortisone ([Florinef] 42.9% versus 45.8%, &lt;em&gt;P&lt;/em&gt;=0.50), they reported in the Jan. 27 issue of the &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;This aggressive treatment strategy should not be routine, the researchers recommended.&lt;/p&gt;
&lt;p&gt;These findings largely match the general lack of benefit seen with tight glycemic control in recent studies with ICU patients overall.&lt;/p&gt;
&lt;p&gt;The prematurely terminated &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/SCCM/5096&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/SCCM/5096&quot; target=&quot;_blank&quot;&gt;European Glucontrol Trial&lt;/a&gt; found no mortality benefit but a seven-fold higher risk of hypoglycemia with an 80 to 110 mg/dL target in the ICU.&lt;/p&gt;
&lt;p&gt;In the &lt;a href=&quot;http://www.medpagetoday.com/CriticalCare/Intensivists/13397&quot; mce_href=&quot;http://www.medpagetoday.com/CriticalCare/Intensivists/13397&quot; target=&quot;_blank&quot;&gt;NICE-SUGAR&lt;/a&gt; study, 90-day mortality was actually higher in the tight glucose control group (27.9% versus 24.9%, &lt;em&gt;P&lt;/em&gt;=0.02), although there was a trend for benefit in patients who got corticosteroids (&lt;em&gt;P&lt;/em&gt;=0.06).&lt;/p&gt;
&lt;p&gt;Glucose targets are being re-evaluated across medicine as the &quot;lower is better&quot; paradigm has had a safety asterisk added everywhere from diabetes care to the ICU, noted Richard Bergenstal, MD, American Diabetes Association president for medicine and science.&lt;/p&gt;
&lt;p&gt;&quot;All of a sudden it&apos;s becoming more than a single number,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;. &quot;Now be it inpatient or outpatient, we&apos;re realizing that ... you have to do it while you&apos;re minimizing hypoglycemia.&quot;&lt;/p&gt;
&lt;p&gt;A more nuanced and &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/13818&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/13818&quot; target=&quot;_blank&quot;&gt;individualized&lt;/a&gt; strategy is prudent, Bergenstal agreed.&lt;/p&gt;
&lt;p&gt;The current clinical uncertainty underscores the need for large-scale international cooperation to get adequately powered trials, according to an accompanying editorial.&lt;/p&gt;
&lt;p&gt;In it, Greet Van den Berghe, MD, PhD, of the Catholic University of Leuven, Belgium, cautioned that Annane&apos;s Corticosteroids and Intensive Insulin Therapy for Septic Shock (COIITSS) study was grossly underpowered.&lt;/p&gt;
&lt;p&gt;The initial studies that led to rapid adoption of intensive insulin therapy in ICUs around the world had suggested an absolute reduction in mortality of only 3%, whereas the COIITSS study projected a 12.5% absolute benefit.&lt;/p&gt;
&lt;p&gt;More importantly, the study achieved mean glucose levels of only between 120 and 130 mg/dL in the intervention group for whom the aim was 80 to 110 mg/dL, which resulted in considerable overlap with the standard care group for whom mean levels were about 145 mg/dL.&lt;/p&gt;
&lt;p&gt;This could account for the lack of difference in outcome, Van den Berghe said.&lt;/p&gt;
&lt;p&gt;But the intensive insulin group did have &quot;markedly&quot; lower blood glucose levels for the duration of their ICU stay and spent more time in the 80 to 110 mg/dL range compared with the standard care group (both &lt;em&gt;P&lt;/em&gt;&amp;lt;0.00001), the researchers noted.&lt;/p&gt;
&lt;p&gt;Because corticosteroids further aggravate the &quot;diabetes of injury&quot; seen with septic shock, Annane&apos;s group undertook a multicenter trial of 509 adults treated for septic shock with multiple organ dysfunction over a three year period at 11 ICUs in France.&lt;/p&gt;
&lt;p&gt;Patients were randomly assigned to tight glucose control using continuous intravenous insulin infusion to target a glucose level of 80 to 110 mg/dL or conventional insulin therapy targeted to guidelines-recommended 150 mg/dL or under. They were additionally randomized to receive hydrocortisone alone (50-mg bolus every six hours) or in combination with fludrocortisone (50-&amp;#956;g tablets once daily) for seven days.&lt;/p&gt;
&lt;p&gt;Aside from the lack of inhospital mortality advantage, tight glucose control also failed to produce a benefit for the following secondary endpoints: &lt;ul&gt; &lt;li&gt;Overall survival (hazard ratio 1.04, &lt;em&gt;P&lt;/em&gt;=0.78) &lt;/li&gt; &lt;li&gt; ICU length of stay for survivors (median 10 versus nine days, &lt;em&gt;P&lt;/em&gt;=0.68)&lt;/li&gt; &lt;li&gt;Duration of hospital stay overall (24 versus 22 days, &lt;em&gt;P&lt;/em&gt;=0.87)&lt;/li&gt; &lt;li&gt;Median vasopressor-free days (four for both, P=0.58)&lt;/li&gt; &lt;li&gt;Median mechanical ventilation-free days (10 versus 13, &lt;em&gt;P&lt;/em&gt;=0.51)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Nor was there evidence for interaction with fludrocortisone in the primary endpoint (relative risk 0.89 versus 0.91 hydrocortisone alone, &lt;em&gt;P&lt;/em&gt;=0.31) or benefit in any other endpoint.&lt;/p&gt;
&lt;p&gt;The one effect of intensive insulin appeared to be an increase in episodes of severe hypoglycemia, defined by glucose falling below 40 mg/dL (mean 0.29 versus 0.14 episodes per patient, &lt;em&gt;P&lt;/em&gt;=0.003).&lt;/p&gt;
&lt;p&gt;However, having hypoglycemia did not increase the risk of death in intervention group patients compared with controls (45.2% versus 50%).&lt;/p&gt;
&lt;p&gt;The researchers cautioned that the study did not rule out a benefit from some degree of glucose control compared with none.&lt;/p&gt;
&lt;p&gt;They also noted that healthcare providers were not blinded to administration of fludrocortisone, for which no placebo was available.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the Assistance Publique&amp;#8211;H&amp;#244;pitaux de Paris. The researchers reported no conflicts of interest.&lt;/p&gt;&lt;p&gt;Van den Berghe, through the Catholic University of Leuven, reported receiving structural research financing from the Methusalem program, funded by the Flemish government.&lt;/p&gt;&lt;p&gt;Bergenstal reported receiving research funding and serving on advisory boards for various pharmaceutical companies related to novel diabetes drugs but without any personal financial compensation.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_2503"
                     title="Targeted Quality Program Improves Neonatal ICU Outcomes"
                     score="-0.006"
                     href="http://www.medpagetoday.com/CriticalCare/Intensivists/tb/15453?impressionId=1265761240758"
                     
      &lt;p&gt;A continuous quality improvement program in Canadian neonatal intensive care units helped reduce the incidence of bronchopulmonary dysplasia and nosocomial infections, a study demonstrated.&lt;/p&gt;
&lt;p&gt;Within-group comparisons of units targeted to reduce nosocomial infections showed a significant decrease in incidence over two years, from 25.4% to 17.4% (OR for one-year incidence change 0.82, 95% CI 0.72 to 0.93, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.01), according to Shoo K. Lee, MBBS, PhD, of the University of Toronto, and colleagues.&lt;/p&gt;
&lt;p&gt;Likewise, units targeted to reduce the incidence of bronchopulmonary dysplasia showed a significant decrease in this outcome, from 29.4% to 24.9% (OR for one-year incidence change 0.70, 95% CI 0.70 to 0.91, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.01).&lt;/p&gt;
&lt;p&gt;And contrary to expectations, the bronchopulmonary dysplasia group also saw a significant decrease in the incidence of nosocomial infections, from 16% to 8.8% (OR for one-year incidence change 0.77, 95% CI 0.66 to 0.90, p&amp;lt;0.01), the researchers reported online, ahead of print, in &lt;em&gt;CMAJ.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;These results emerged from a cluster randomized trial evaluating the Evidence-based Practice for Improving Quality (EPIQ) method, which relies on evidence in the literature, collection of data from participating hospitals to identify hospital-specific practices for targeted intervention, and the use of a national network for sharing expertise.&lt;/p&gt;
&lt;p&gt;The investigators chose six neonatal intensive care units for targeted interventions to reduce nosocomial infections, six for targeting to reduce bronchopulmonary dysplasia, and an addition five to serve as a comparison group.&lt;/p&gt;
&lt;p&gt;The yearlong phase 1 of the study involved preparation for the intervention, with establishment of multidisciplinary teams that included site investigators, neonatologists, nurses, and other specialists who were trained in quality improvement and sought to identify barriers to change.&lt;/p&gt;
&lt;p&gt;Phase 2 took place during years 2 and 3, during which the hospital teams implemented rapid cycles of practice change that lasted one to three months, with communication strategies that included information sessions, focus groups, and computer-based learning resources.&lt;/p&gt;
&lt;p&gt;The study included 2,465 infants in the infection group, 3,070 in the pulmonary group, and 984 in the comparison group, all born at 32 weeks&apos; gestation or less.&lt;/p&gt;
&lt;p&gt;The investigators hypothesized that the incidence of nosocomial infection would be decreased in units targeted to reduce infection  --  but not in units targeted to reduce bronchopulmonary dysplasia, and vice versa.&lt;/p&gt;
&lt;p&gt;As expected, within-group comparisons of the infection group showed a significant decrease in the incidence of nosocomial infections from baseline, but there was no significant change in incidence of bronchopulmonary dysplasia, from 31.8% to 30.6% (OR for one-year incidence change 0.98, 95% CI 0.85 to 1.12).&lt;/p&gt;
&lt;p&gt;In the pulmonary group, along with the decreases in infection and pulmonary dysplasia, there was a decrease on the composite endpoint of death and pulmonary dysplasia from baseline, from 35% to 30.7% (OR for one-year incidence change 0.80, 95% CI 0.70 to 0.92).&lt;/p&gt;
&lt;p&gt;Although between-group comparisons found that the incidence trends for bronchopulmonary dysplasia and for death and bronchopulmonary dysplasia were significantly different (&amp;#8210;0.0006, 95% CI &amp;#8210;0.0011 to &amp;#8210;0.0001, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.05), the incidence trends for nosocomial infections were similar (&amp;#8210;0.0002, 95% CI &amp;#8210;0.0007 to 0.0004).&lt;/p&gt;
&lt;p&gt;In an accompanying editorial, William McGuire, MD, of Hull York Medical School in England and Peter W. Fowlie, MB ChB, of Ninewells Hospital and Medical School in Dundee, Scotland, offered an explanation for this lack of significance.&lt;/p&gt;
&lt;p&gt;&quot;The widespread use of the infection-control interventions included in the EPIQ method may be the cause of the failure to detect an effect of the interventions on the incidence of nosocomial infection,&quot; the editorialists wrote.&lt;/p&gt;
&lt;p&gt;Specifically, infection control measures that would be likely to have an effect, such as aseptic management of central vascular lines and restrictions on the use of antibiotics, were already in place in most of the centers before the quality improvement effort began.&lt;/p&gt;
&lt;p&gt;The Canadian researchers suggested that interventions targeting one outcome could influence others.&lt;/p&gt;
&lt;p&gt;&quot;Because quality improvement is about transforming behaviors, spillover from one outcome to another may be expected,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;&quot;We speculate that the decrease in the incidence of nosocomial infections in the pulmonary group was related to improved lung status and a reduced need for assisted respiration, invasive interventions, improved feeding and growth, and better overall health.&quot;&lt;/p&gt;
&lt;p&gt;Limitations of the study included the use of a subjective definition of bronchopulmonary dysplasia (oxygen dependency at 36 weeks&apos; corrected gestational age), concerns about anonymity that may have limited feedback, and logistical delays in reporting.&lt;/p&gt;
&lt;p&gt;The investigators also noted that their approach may be generalizable to other areas of healthcare, enchancing the efficacy and cost-effectiveness of quality improvement efforts.&lt;/p&gt;
&lt;p&gt;The study was funded by the Canadian Institutes of Health Research, as well as by multiple other health foundations and hospitals.&lt;/p&gt;
&lt;p&gt;The authors declared no competing interests.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20090101_19_2817"
                     title="Communication Skills Missing from Neonatal Training (CME/CE)"
                     score="-0.006"
                     href="http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/tb/15864?impressionId=1265761240758"
                     
      &lt;p&gt;More than 90% of doctors in the final year of a neonatology fellowship think there&apos;s a need for better training in communication skills, researchers said.&lt;/p&gt;
&lt;p&gt;In a Web-based survey of 162 fellows graduating in 2008, 41% said they had no formal communication training, and 93% said such training needs improvement, according to Renee Boss, MD, of Johns Hopkins University School of Medicine in Baltimore, and colleagues.&lt;/p&gt;
&lt;p&gt;They reported intensive training in medical management of extremely premature infants or dying newborns  --  96% and 89% respectively  --  Boss and colleagues said in the September issue of &lt;em&gt;Archives of Pediatrics and Adolescent Medicine.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;But, the researchers found: &lt;ul&gt; &lt;li&gt; 42% said they had never taken part in specific didactic conferences or courses aimed at teaching them how to communicate such issues with parents&lt;/li&gt; &lt;li&gt;75% had never participated in a relevant role play or simulated patient scenario&lt;/li&gt; &lt;li&gt;Only 6% had taken a clinical rotation that was primarily focused on developing communication skills&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The survey, taken in May 2008, had valid e-mail addresses for 140 of the 162 graduating fellows in 29 states and Puerto Rico. Of those, 101 completed the survey, for a 72% response rate (or 62% of all graduating fellows).&lt;/p&gt;
&lt;p&gt;The participating doctors came from 83% of all the neonatal-perinatal training programs with graduating fellows, the researchers said.&lt;/p&gt;
&lt;p&gt;Despite the lack of formal training, 94% of the fellows said they were &quot;sometimes or always&quot; responsible for leading family meetings to discuss goals of care.&lt;/p&gt;
&lt;p&gt;On the other hand, only 40% said an attending physician was in the room and gave consistent feedback later, and 14% said they had never been given feedback by an attending physician.&lt;/p&gt;
&lt;p&gt;Participants generally thought that formal training in communication was more important to them than to faculty, the researchers found.&lt;/p&gt;
&lt;p&gt;On a seven-point Likert scale, where 1 was not at all important and 7 was very important, the fellows on average reported the importance of training to be a 6.3.&lt;/p&gt;
&lt;p&gt;On the other hand, they said such training appeared to rate a 5.7 for faculty, a difference that was significant at &lt;em&gt;P&lt;/em&gt;=0.007.&lt;/p&gt;
&lt;p&gt;One limitation of the study, Boss and colleagues said, is that the researchers used self-reporting to assess training in communication skills and did not confirm those reports with the individual programs.&lt;/p&gt;
&lt;p&gt;The findings are not surprising, according to M. Douglas Jones, Jr., MD, of the University of Colorado Denver School of Medicine.&lt;/p&gt;
&lt;p&gt;&quot;Communication is surely part of the &apos;art of medicine,&apos;&quot; he said in an accompanying editorial. &quot;Yet no artist succeeds without first becoming, with mentored practice, an expert craftsman.&quot;&lt;/p&gt;
&lt;p&gt;The lack of training may arise because faculty are not sure how to teach communication skills, Jones said, or it may be a result of intense concentration on a curative approach to care.&lt;/p&gt;
&lt;p&gt;The researchers &quot;have done us the favor of describing the problem,&quot; Jones said. &quot;We have to understand how we can improve and, just as important, why, in a matter of such importance, we still have such a problem.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the NIH.&lt;/p&gt;&lt;p&gt;The researchers made no disclosures.&lt;/p&gt;&lt;p&gt;Dr. Jones, the editorialist, made no disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>