Description
This is a continuation of the assignment completed a week ago. Please see the attached instructions for responses to the discussions per the instructions below, and let me know if you have additional questions. I attached each post, making it a total of 3, so we need responses to each of them on the attached pages to avoid confusion.Students must respond to at least 3 of their fellow classmate’s articles.Response PostsResponse length: 0.5 page
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Treating inpatient hypertension
Topic of choice: When do we treat inpatient hypertension?
This came from a discussion with my hospitalist preceptor as we discussed inappropriate
paging/abuse of Epic SecureChat, and when it is appropriate for nurses to page about blood
pressure management.
Article: Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac
Admissions, 2021
Citation:
Rastogi, R., Sheehan, M. M., Hu, B., Shaker, V., Kojima, L., & Rothberg, M. B. (2021).
Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac
Admissions. JAMA internal medicine, 181(3), 345–352.
https://doi.org/10.1001/jamainternmed.2020.7501
Additional reading just for fun/interest: How should asymptomatic hypertension be
managed in the hospital? (2018)
Summary:
Rastogi et al. (2021) is a cohort study that sought to add to a lacking body of evidence
surrounding hypertension treatment in the inpatient setting. This article specifically focused
on patients who are admitted for noncardiac reasons. The cohort was made up of 22,834
patients admitted between 3-13 days and chart reviews were performed to make sure they
met criteria: 18+ years of age, not pregnant, admitted to medicine service, no admissions for
cardiovascular diagnosis or cerebrovascular event within 30 days, and no cardiovascular
diagnosis as admission diagnosis. The patients were admitted across 10 hospitals.
Measurements taken into consideration were SBP and DBP, as well as heart rate, and
measurements from the ICU were excluded. They decided to use SBP > 140 mmHg as their
standard definition of hypertension. As a part of the chart review, all prior to admission (PTA)
medications were evaluated along with comorbidities of the patients in the study. Further
exploration of the study design and considerations can be found in the article.
There were three phases of analysis: acute treatment of elevated BP, inpatient events
following high blood pressure or after treatment, and lastly the intensification of medication at
time of discharge. Of the patients included in the study, there were abou t 17,810 of the 22,
834 (78%) had at least one elevated blood pressure reading, and about one third of those
were treated. Patients were primarily treated with oral antihypertensives but IV, PO, IM, and
topical administrations were all taken into consideration. Of the patients treated, there were
more listed risk factors for cardiovascular disease and complications such as older
age/African American, and blood pressure readings tended to be higher.
When determining whether or not blood pressure management was helpful vs harmful
in these patients, researchers defined harmful as “resulting in end-organ damage”. End
organ damage was defined as acute kidney injury (AKI), myocardial injury, stroke, and a
composite of all three of these diagnoses. In order to be included in the study, these
outcomes had to occur after the elevated blood pressure reading. Interestingly enough,
those who were treated for elevated blood pressure were actually more likely than the
control patients to end up with AKI or myocardial injury, and results were similar
between those who received PO vs IV treatments. The study found that there were no
greater outcomes with patients who were treated vs left untreated. SBP readings that were
extremely elevated over 220 mmHg were treated 47% of the time. This lack of treatment is
interesting considering that about 80% of resident physicians believed that hypertension
while admitted was a high priority. About one third of hospitalists believed that asymptomatic
hypertension, above 182/100, was reason enough to transfer the patient into the ICU. In
summary, researchers came to the conclusion that “intensification of therapy without signs of
end-organ damage was associated with worse outcomes”.
Upon discharge from the hospital, it was found that about 8% of the patients with
elevated blood pressure readings actually had medication regimens intensified. When it was
intensified, it was not always found to be helpful in overall management.
We do not know exactly when hypertension in the inpatient setting is caused by pain,
nausea, fever, or stress, nor do we know whether or not elevation of BP in these settings is
adaptive vs harmful.
Potential flaws:
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Patients with diagnosis of atrial fibrillation or heart failure were included, but those
with cardiovascular diagnoses that require specific BP management were not
(ACS/CVA)
Other signs of end organ damage may not be as easily measured as AKI, stroke, or
MI and could be missed
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Potential practice changes:
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Treat hypertension conservatively
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Is the reading a one off or a trend?
Is the patient symptomatic? And are there signs of end organ damage?
Education among nursing staff regarding symptoms or changes in patient condition
associated with high blood pressure readings
Hospital Surgical Volume and Emergency
General Surgery Outcomes
Hospital Volume of Emergency General Surgery and its Impact on Inpatient Mortality
for Geriatric Patients: Analysis From 3994 Hospitals
This study assessed associations between inpatient surgical outcomes and hospital
case volume for emergency surgery. This was a population-based
retrospective cohort study that used the CMS limited data set files from 2011 to
2013. The cohort was 414,779 patients from 3994 hospitals. This assessed the 7 most
common emergency surgeries evaluated were partial colectomy, small-bowel
resection, cholecystectomy, appendectomy, lysis of adhesions, operative management
of peptic ulcer disease, and laparotomy.
Patients were included in the data analysis if their procedures were considered
emergency or urgency (and they were excluded if considered elective procedures).
Patients were included if their ICD-9 diagnosis met that of the 7 most common
emergency surgeries listed. Patients under 65 were excluded because of significant
comorbidities present in those less than 65 who are on medicare or medicaid; this
dataset is only CMS patients.
The primary outcome assessed was death occurring between admission and discharge;
secondary outcome was length of stay.
Data was analyzed with covariates: the primary independent variable was hospital
surgical volume, but other known or possible covariates were adjusted for. Variables
considered included age range, time of visit, teaching hospital status, transfer-in
status, and gender. Also season of admission, US state, socioeconomic status via
presence of co-insurance along with medicare, and comorbidity per the Charlston
comorbidity index.
A two-way comparison was conducted to describe correlation of covariates to
patients who received surgery in a high-volume center versus a patient in a lowvolume center. A model defining expected death rates was developed, and the death
rates of each hospital for each type of surgery was compared to this standard.
The process of dividing facilities into “high-volume” and “low volume” centers was not
evident.
In analysis of the data, baseline characteristics of high-volume vs. low-volume centers
was: many more total operations in the dataset were performed at low-volume
hospitals. There were no socio-demographic differences between high and lowvolume hospitals. However, high-volume centers had patients with significantly more
comorbidities.
There was significantly better mortality in high-volume centers for patients who
underwent partial colectomy or small bowel resection.
-Surgical technical complications were generally no different between groups.
However, high surgical volume centers had better rates of pneumonia, sepsis, and
cardiac arrest in small bowel resection patients. High surgical volume centers had
better rates of pneumonia and cardiac arrest for colectomies.
Cholecystectomy, lysis of adhesions, appendectomy, and multiple surgery procedures
had better mortality in high-volume centers (not statistically significant)
Laparotomy & Peptic ulcer disease surgeries had better mortality in low-volume
centers (not statistically significant). Maybe this is because there are more critically ill
patients for these operations at high-volume centers. It is hard to account for the
gestalt of low-volume center surgeons who decide to refer on specific acute surgical
issues. Patients receiving these issues at high-volume centers had significantly more
patients with multi-organ failure; and those having ulcer surgery at high-volume
centers were significantly more likely to have had chronic kidney disease. Per the
authors, other research seems to show that extra time taken to send a peptic ulcer
perforation/bleeding to a higher-volume center causes more death instead of doing
emergency surgeries in the lower volume center.
Overall, there may be more to just the surgical skill at high volume centers that
improves outcomes for colectomies and small bowel resection. It may be the
interdisciplinary care, resources, and other perioperative care that help prevent
postoperative complications like pneumonia, sepsis, and cardiac arrest.
For people in America over 65, having small bowel resections or colectomies done at
low-volume centers does seem to be worse than having them completed at highvolume centers. Also, emergency surgical outcomes may be better in general at highvolume centers; this may be related to perioperative care differences and not so much
the surgical skill and techniques. Systems-based approach for perioperative care may
improve surgical outcomes in lower-volume centers to that of higher volume centers.
One must remember that this is a retrospective study that appears to show some
correlations. No causative claims can be made, but the analysis of many different
covariates helps to describe these phenomena.
Ang, D., Sugimoto, J., Richards, W., Liu, H., Kinslow, K., McKenney, M., Ziglar, M., &
Elkbuli, A. (2023). Hospital Volume of Emergency General Surgery and its Impact on
Inpatient Mortality for Geriatric Patients: Analysis From 3994 Hospitals. The American
Surgeon, 89(4), 996–1002. https://doiorg.akin.css.edu/10.1177/00031348211049251
NSG 8712: Acute Care Adult Gerontology Practicum II
Journal Club Discussion
●
Students will select an evidence-based article pertinent to acute care that is less than three years
old. Students will analyze the article, write a brief summary or record a brief summary to be
posted to Brightspace and discuss potential practice changes.
○ Brief, in this assignment, means 1-2 pages or 5 mins if recorded. Journal Club in a
professional setting typically is just that, a brief summary of an article, the statistical
analysis, potential flaws, and potential practice changes.
Discussion Post Grading Rubric
Critical Thinking
20-16 pts
Outstanding:
-Rich in content
-Full of thought
-Insightful
-Broad
Understanding of
Topic
15-11 pts
Proficient:
-Substantial
Information
-Evident that
thought, insight,
and analysis of
sorts has taken
place
110-6 pts
Basic:
-General
information
-Thought,
insight, analysis
is commonplace
5-0 pts
Below
Expectations:
-Rudimentary
and superficial
-Incomplete
Understanding and
Applications of
Concepts
20-16 pts
Outstanding:
-Content applies
to personal and
professional
practice
-Examples of
health care
delivery systems
15-11 pts
Proficient:
-Content of
posting reflects
full
understanding of
concepts with
some application
10-6 pts
Basic:
-Content of post
reflects basic
understanding of
concept little to
now application
5-0 pts
Below
Expectations:
-Content of post
does not reflect
understanding or
concepts
-Incomplete
Application and
Analysis of
Professional
Resources
20-16 pts
Outstanding:
-Post
incorporates
assigned reading,
lessons, expert
opinion, peer
reviewed
content, and life
experiences
15-11 pts
Proficient:
-Post
incorporates
only assigned
reading or life
experiences
10-6 pts
Basic:
-Post
incorporates
mostly expert
opinion or life
experiences
5-0 pts
Below
Expectations:
-Post does not
incorporate
sources and lacks
professional
resources
-Incomplete
Professionalism
20-16 pts
Outstanding:
-Clear, logical
-Grammar
-Respectful
-Actively
engaged in
responses
15-11 pts
Proficient:
-Clear, logical
-Few
grammatical
errors
– Responds but
not actively
engaged
10-6 pts
Basic:
-Obvious errors
in information
-Responses show
lack of
engagement
-Low
engagement
5-0 pts
Below
Expectations:
-Copious Errors
-Difficult to
understand
-Defensive or
disrespectful in
postings
Timeliness
20-16pts
Outstanding:
Posts
15-11pts
Proficient:
1-2 days late
10-6pts
Basic:
>2 days late
5-0 pts
Below
Expectations:
> 3 days late
-Incomplete
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