1. Chu, Julie J. MSN, CRNP

Article Content


More effective than computerized physician reminders.

The use of computerized standing orders for nurses to administer influenza and pneumococcal vaccines to eligible inpatients is more effective than the use of computerized physician reminder systems, according to a recently published study.


From November 1998 through December 1999, a period encompassing two influenza seasons, eight general medical physician teams at an urban public teaching hospital were randomly assigned to either a computerized standing orders group or a computerized physician reminder group (control) to compare the vaccination rates among 3,777 hospitalized patients in their care. In both groups, the computer searched for patients eligible for the vaccinations (those older than 65, those with a chronic illness that increased the susceptibility to influenza or pneumonia, and those with no record of having received vaccination according to the recommended time frame). For patients deemed eligible to receive either vaccination, the computer either generated standing orders for nurses to administer it at discharge or sent reminders to physicians that had to be accepted by them in order for vaccination orders to be transmitted to the nurses during patients' hospitalizations. The primary outcome was the vaccination rate.


Half of those hospitalized during the influenza seasons (848 patients) were deemed eligible for the influenza vaccination (n = 385, standing orders group; n = 463, control group). Significantly more patients in the standing orders group (42%) received vaccinations, compared with those in the control group (30%).


Likewise, 829 patients (22% of those hospitalized during the study period) were noted to be eligible for the pneumococcal vaccination (n = 406, standing orders group; n = 423, control group). Fifty-one percent of patients in the standing orders group received the vaccination, compared with only 31% of those in the control group. Large proportions of the unadministered influenza and pneumococcal vaccinations, 63% and 58%, respectively, were attributable to eligible patients' declining to receive them.


According to the researchers, the use of computerized standing orders for vaccination of eligible patients appears to be an easily applied practice that increases vaccination rates. However, the great percentage of patients who declined vaccination during the study indicates that more education on the vaccinations should be provided to correct any misconceptions held about risks incurred in receiving them.


Dexter PR, et al. JAMA 2004;292(19):2366-71.



Study reveals the predictors.

A large study of patients with ischemic stroke reveals that not only are there differences in the predictors of death in the hospital among men and women in the short term, pneumonia and increased intracranial pressure are the complications most likely to cause death after the stroke in that setting.


During 2000 researchers studied 13,440 ischemic stroke patients admitted to hospitals participating in the German Stroke Registers Study Group to determine the predictors of inhospital death and the specific medical and neurologic complications causing death. Researchers analyzed the effects of age, hypertension, diabetes mellitus, previous stroke, atrial fibrillation, stroke severity, and destination at discharge on in-hospital mortality rates. The risks of death associated with medical and neurologic complications during hospitalization, such as recurrent stroke, pulmonary embolism, epileptic seizure, pneumonia, and increased intracranial pressure, also were investigated.


Overall, the in-hospital mortality rate was 4.9%. Multivariate analyses showed that the independent predictors of inhospital mortality in women were older age (more than 65 years), greater stroke severity (affliction with two or more neurologic deficits), and atrial fibrillation. The predictors among men included those factors, as well as the presence of diabetes and previous stroke. Increased intracranial pressure and pneumonia were the complications associated with the greatest risk of death during hospitalization. In fact, 94% of patients with ischemic stroke who also had increased intracranial pressure died because of it, while 31.2% of patients in the entire population of stroke patients died of pneumonia. The medical and neurologic complications examined during the study accounted for more than half of all the inhospital deaths during the year.


According to the researchers, the results of the study may help clinicians to better direct interventions among patients admitted to the hospital with ischemic stroke, particularly in regard to the prevention and treatment of increased intracranial pressure and pneumonia.


Heuschmann PU, et al. Arch Intern Med 2004;164(16):1761-8.