I like studies that question accepted practices. I also like to question studies that question accepted practices. [See this post about discrediting discredited practices.]
Here are three studies with surprising and thought-provoking results.
A few years ago, the idea of rapid response teams surfaced. These teams were supposed to be called when patients on regular floors became unstable. It was thought that such teams would be able to intervene more rapidly than simply paging the patient’s physician. Nearly every hospital established rapid response teams, and early studies tended to confirm that they were efficacious. So, all was well.
But a recent paper from Critical Care Medicine shows that rapid response teams increase costs and intensive care unit admissions without showing any improvement in risk-adjusted patient outcomes. Naysayers will complain that it wasn’t a randomized, prospective, double-blind study. But it was a large before-and-after cohort study from a respected institution–the Mayo Clinic–and it is probably impossible to do a randomized trial now. The authors concluded that hospitals should at least evaluate their own experiences with rapid response teams.
Another study, this time in JAMA, questions the validity of using rates of venous thromboembolic events as markers of hospital quality. It seems the more diligently one looks for VTEs, the more one finds them. Hospitals that did more imaging studies looking for VTEs had significantly higher rates of VTE. It’s called “surveillance bias.” The hospitals with high rates of VTE also had significantly higher rates of adherence to prophylaxis guidelines. So, if a patient was looking for a hospital with high-quality care in the area of venous thromboembolic events, the rate of VTEs might be very misleading.
A third study, also from JAMA, was a randomized trial in 20 American ICUs, 10 of which involved healthcare workers donning gowns and gloves for all patient contact and 10 where gown and glove use was required only for patients with established MRSA or VRE colonization or infection. More than 26,000 patients were included. Although the acquisition of MRSA or VRE declined from baseline in both groups, the difference was not statistically significant between the two groups. [Digression: this may have been due to the famous “Hawthorne Effect,” which is that behavior improves when subjects are aware that they are being watched.]
Other interesting findings were that personnel in the group that wore gowns and gloves for all patients entered patient rooms significantly less frequently. The rate of occurrence of the adverse events was not different in the two groups.
Rapid response teams may not be as useful as once thought. They do lead to increased costs and ICU admissions.
Hospitals with higher rates of VTE may actually be better-quality hospitals than those with lower rates.
Observing gown and glove precautions for all patients in ICUs does not appear to affect the rate of acquisition of antibiotic-resistant organisms.
Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1400 page views per day, and he has over 8700 followers on Twitter.
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