Wednesday, February 21, 2018

Lit Bits: Feb 21, 2018

From the recent medical literature...

1. New Guidelines: CVA and Pancreatitis

A. AHA/ASA Extend Thrombectomy Window to 24 Hours and Expand Lytic Criteria

by Crystal Phend, Senior Associate Editor, MedPage Today, January 24, 2018

LOS ANGELES -- In a radical move for the typically glacial pace of comprehensive guideline overhaul, the American Heart Association/American Stroke Association expanded the treatment window for endovascular thrombectomy within hours of release of supporting trial data.

The guideline, released here at the International Stroke Conference (ISC) and online in Stroke, moved from a 6-hour time frame for stent retriever use to up to 24 hours after patients with acute ischemic stroke were last known to be well. The recommendation was class Ia for the period from 6 to 16 hours as both the DAWN trial and the DEFUSE 3 trial, released the same day here at ISC, confirmed better outcomes than medical therapy alone; it was a IIa recommendation out to 24 hours, reflecting that only a single trial for this window (DAWN) was available.

"This will be perhaps a once in a lifetime situation where a study gets published [and] within 2 hours is incorporated into new guidelines," DEFUSE 3 presenter Gregory Albers, MD, of Stanford University in Stanford, California, said at a press conference. He noted that this was made possible by provision of an embargoed copy of the trial to the guideline-writing group.

The guidelines recommend physicians use either DAWN or DEFUSE 3 criteria for determining which large vessel occlusions are candidates for clot removal. DEFUSE 3 used broader inclusion characteristics (mainly in allowing a larger ischemic core and less severe strokes), with about 40% of participants not fitting DAWN criteria.

Basically, that comes down to being as generous as possible in inclusion to reach "anybody who is eligible based on either one" before the 16-hour window, but follow DAWN criteria from past 16 hours to 24 hours, guideline writing committee chair William Powers, MD, of the University of Chapel Hill in North Carolina, told MedPage Today at the press conference.

While Mark Alberts, MD, of Hartford HealthCare in Hartford, Connecticut, noted that his center had already adopted the 24-hour strategy based on DAWN, they will consider the two in resetting criteria. "Our stroke staff will meet and we'll discuss them. I think that's what's going to go on in most systems; they'll come up with a happy medium."

That also necessitated a shift to the guidelines recommending more sophisticated imaging, specifically diffusion weighted MRI or MRI perfusion to aid in patient selection for mechanical thrombectomy. In practical terms, these changes are likely to increase the thrombectomy-eligible population by 20% nationwide, commented Jeffrey Saver, MD, of the University of California Los Angeles.

"Now ... it doesn't matter where you are, there's nowhere in the country that you can't get to a [thrombectomy] center in 24 hours," Albers noted. However, "there's a lot of work to be done," toward the class Ia recommendation for development of regional systems of care that remained unchanged from the 2015 update, Powers noted. Each individual region has many issues to work out with "no easy recipe" that all can follow, he said. Now adding the complexities of thrombectomy scans and transfers, "it's a new world," agreed Albers.

Thrombolytics, too, saw some changes in the guidelines. Overall, the recommendations for IV thrombolysis were broadened, with an increase in indications and reduction in absolute contraindications, such as recent dural puncture or non-major head trauma. Use in otherwise eligible patients with mild stroke even in 3 to 4.5 hour windows was also deemed reasonable.

Other changes included:

  • Prevention of deep vein thrombosis for immobile patients during the hospital stay should focus on intermittent pneumatic compression (upgraded to class I) instead of heparin, which was downgraded from a Ia to IIb recommendation
  • Candidates for carotid endarterectomy should be evaluated for that within 24 hours and surgery should occur within 7 days
  • Acute blood pressure management recommendations got downgraded to reflect increasingly equivocal evidence of benefit 
The guidelines were also endorsed by the American Association of Neurological Surgeons, Congress of Neurological Surgeons, and the Society for Academic Emergency Medicine.

New AHA Guidelines: Powers WJ, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Jan 24 [Epub ahead of print].

DAWN Trial (reviewed in January’s Lit Bits):

B. New Amer Gastro Assn guideline steers early treatment for acute pancreatitis

A new clinical guideline from the American Gastroenterological Association provides up-to-date recommendations for early treatment decisions in acute pancreatitis.

Aiming to promote consistent practices and quality care, the new guideline focuses on clinical decisions made within the first 48 to 72 hours of hospital admission for acute pancreatitis, which can “alter the course of disease and duration of hospitalization.” It includes recommendations on goal-directed fluid resuscitation, early oral feeding, enteral vs. parenteral nutrition, routine prophylactic antibiotic use and routine endoscopic retrograde cholangiopancreatography (ERCP).

According to the guideline committee, acute pancreatitis is a leading gastrointestinal cause of inpatient care. More than 275,000 patients are hospitalized per year costing more than $2.6 billion in the U.S., and evidence suggests incidence is on the rise.

The guideline issued four “strong” recommendations based on moderate quality evidence, including:
  • Oral feeding should be given within 24 hours as tolerated rather than following the “nothing by mouth” or nil per os (NPO) practice;
  • Enteral rather than parenteral nutrition should be used in patients who are unable to feed orally;
  • Cholecystectomy should be performed at initial admission in patients with acute biliary pancreatitis, rather than after they are discharged; and
  • A brief alcohol intervention should be performed during admission in patients with acute alcohol-induced pancreatitis.

Guidelines: Crockett SD, et al. Gastroenterol. 2018 Feb 3 [Epub ahead of print]

2. ED Patients with Chest Pain

A. Performance of coronary risk scores in patients with CP in the ED.

Mark DG, et al, with the KP CREST Network. J Am Coll Cardiol. 2018;71(6):606-616.

BACKGROUND: Both the modified History, Electrocardiogram, Age, Risk factors and Troponin (HEART) score and the Emergency Department Assessment of Chest pain Score (EDACS) can identify patients with possible acute coronary syndrome (ACS) at low risk (less than 1%) for major adverse cardiac events (MACE).

OBJECTIVES: The authors sought to assess the comparative accuracy of the EDACS (original and simplified) and modified HEART risk scores when using cardiac troponin I (cTnI) cutoffs below the 99th percentile, and obtain precise MACE risk estimates.

METHODS: The authors conducted a retrospective study of adult emergency department (ED) patients evaluated for possible ACS in an integrated health care system between 2013 and 2015. Negative predictive values for MACE (composite of myocardial infarction, cardiogenic shock, cardiac arrest, and all-cause mortality) were determined at 60 days. Reclassification analyses were used to assess the comparative accuracy of risk scores and lower cTnI cutoffs.

RESULTS: A total of 118,822 patients with possible ACS were included. The 3 risk scores' accuracies were optimized using the lower limit of cTnI quantitation (less than 0.02 ng/ml) to define low risk for 60-day MACE, with reclassification yields ranging between 3.4% and 3.9%, while maintaining similar negative predictive values (range 99.49% to 99.55%; p = 0.27). The original EDACS identified the largest proportion of patients as low risk (60.6%; p less than 0.0001).

CONCLUSIONS: Among ED patients with possible ACS, the modified HEART score, original EDACS, and simplified EDACS all predicted a low risk of 60-day MACE with improved accuracy using a cTnI cutoff below the 99th percentile. The original EDACS identified the most low-risk patients, and thus may be the preferred risk score.

B. Myths in EM: Even if Stress Tests Found Patients at High Risk for MI (They Don't), To What End?

Spiegel R. Emerg Med News. 2018;40(1):10-11

Whether you are aware of it or not, you make three major assumptions every time you employ any diagnostic strategy in the emergency department—that the diagnostic test will identify patients at risk of a poor outcome because of an undiagnosed process, that an effective intervention will avert that outcome, and that discovering this process early will make the intervention more effective than if we had waited for the disease to manifest clinically obvious characteristics.

These assumptions are frequently based purely on physiological reasoning and good intentions, but these are poor surrogates for patient-oriented outcomes and often fail to survive the test of scientific inquiry. Such is the case for noninvasive cardiac testing. Multiple studies suggest its ineffectiveness, but the stress test has maintained its lofty position for managing patients presenting to the ED with chest pain.

A recent study by Sandhu, et al., utilized a large insurance claims database to identify patients who presented to the ED with chest pain and compared outcomes in patients who did or did not undergo noninvasive testing. (JAMA Intern Med 2017;177[8]:1175.) The authors used a fairly novel and elegant approach to control for the many imbalances one would expect from such a large, heterogeneous, nonrandomized cohort.

Using what is called an instrumental-variables approach, the authors exploited the fact that care is not delivered consistently across all seven days of the week. Their premise, according to previous data, was that patients seen in the ED on the weekend (Friday-Sunday) were less likely to undergo stress testing than those who presented Monday-Thursday, based not on differences in patient-level characteristics, but rather the universal distaste of working on the weekend.

The researchers excluded patients with diagnoses suggestive of acute ischemia and those whose chest pain could be explained with an alternate diagnosis, and they identified 926,633 unique adult ED visits from 2011 to 2012. Unsurprisingly, patients who received testing were older, with more risk factors than patients who did not undergo testing. Conversely, patients who presented on the weekend appeared to be fairly similar at baseline when compared with those who presented during the week.

Downstream Testing
As the authors predicted, patients evaluated on the weekend underwent less stress testing when compared with those who presented during the week (18.18% vs 12.30%). They also observed more early angiography (2.10% vs 1.30%) and downstream testing, defined as any invasive or noninvasive testing done over the next 30 days (26.10% vs 21.35%). Even after adjusting for possible bias, not controlled for with their instrumental approach, the authors noted an increase in the rates of invasive angiography in patients who presented on the weekday when compared with those who presented on the weekend. They also noted that this increase in invasive or noninvasive testing did not lead to an observed decrease in the rate of myocardial infarction.

Despite the elegance with which these authors manipulated this large unwieldy dataset, its innate structure creates the potential for multiple sources of bias that cannot be controlled by any statistical manipulations. That said, their results are fairly consistent with the majority of the previous literature examining noninvasive stress testing. More importantly, the stress test has failed to meet the three initial assumptions required when examining any diagnostic testing strategy.

The concept that noninvasive stress tests identify a population at higher risk for a myocardial infarction is based on poor data. Amsterdam, et al., using a prospective dataset, claimed that patients with positive stress tests were at significantly higher risk of adverse events than those with negative tests (17% vs 0.16%). (J Am Coll Cardiol 2002;40[2]:251.)…

The rest of the myth-busting review (full-text free):

Sandhu abstract in JAMA Intern Med:

3. Sex Differences in AMI and CVA

A. Sex Differences in the Presentation and Perception of Symptoms Among Young Patients With MI: Evidence from the VIRGO Study

Lichtman JH, et al. Circulation. 2018;137:781-790.

What Is New?
Sex differences in symptom presentation for acute myocardial infarction have been shown in older populations, but less is known about potential sex differences in self-reported symptoms, perception of symptoms, and self-reported care-seeking behavior in young patients with acute myocardial infarction.

Based on direct patient interviews, almost 90% of young women and men presented with chest pain, pressure, tightness, or discomfort; women were more likely to present with ≥3 additional non–chest pain symptoms in comparison with men.

Among patients who sought care for symptoms before their hospitalization, women were less likely to be told their symptoms were heart-related.

What Are the Clinical Implications?
Chest pain, pressure, tightness, or discomfort is the hallmark symptom for young patients presenting with acute myocardial infarction.

Presentation with multiple non–chest pain symptoms may influence the decision to initiate a workup for ischemic heart disease, particularly if chest pain or the various ways chest pressure is described is not the primary or most emphasized symptom.

Most of the young patients in the VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) had ≥1 traditional cardiac risk factor; physicians should listen carefully and consider the diagnosis of heart disease in young patients, particularly those with multiple cardiac risk factors who mention chest pain, pressure, tightness, or discomfort in a history.

B. Neurology Concepts: Young Women and Ischemic Stroke-Evaluation and Management in the ED.

Chang BP, et al. Acad Emerg Med 2018; 25(1):54-64

OBJECTIVE: Ischemic stroke is a leading cause of morbidity and mortality worldwide. While the incidence of ischemic stroke is highest in older populations, incidence of ischemic stroke in adults has been rising particularly rapidly among young (e.g., premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department, due to a range of sex-specific risk factors and to broad differentials. The goals of this concepts paper are to summarize existing knowledge regarding the evaluation and management of young women with ischemic stroke in the acute setting.

METHODS: A panel of six board-certified emergency physicians, one with fellowship training in stroke and one with training in sex- and sex-based medicine, along with one vascular neurologist were coauthors involved in the paper. Each author used various search strategies (e.g., PubMed, PsycINFO, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors.

RESULTS: Estimates on the incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per 100,000 in the United States. Several risk factors for ischemic stroke exist for young women including oral contraceptive (OCP) use and migraine with aura. Pregnancy and the postpartum period (up to 12 weeks) is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35. Current evidence regarding the management of acute ischemic stroke in young women is also summarized including use of thrombolytic agents (e.g., tissue plasminogen activator) in both pregnant and nonpregnant individuals.

CONCLUSION: Unique challenges exist in the evaluation and diagnosis of ischemic stroke in young women. There are still many opportunities for future research aimed at improving detection and treatment of this population.

4. Pediatric Corner

A. Oral Analgesics Utilization for Children with Musculoskeletal Injury (OUCH Trial): An RCT.

Le May S, et al. Pediatrics. 2017 Nov;140(5).

BACKGROUND: Musculoskeletal injuries (MSK-Is) are a common and painful condition among children that remains poorly treated in the emergency department (ED). We aimed to test the efficacy of a combination of an anti-inflammatory drug with an opioid for pain management of MSK-I in children presenting to the ED.

METHODS: In this randomized, double-blinded, placebo-controlled trial, we enrolled children between 6 and 17 years presenting to the ED with an MSK-I and a pain score above 29 mm on the visual analog scale (VAS). Participants were randomly assigned to oral morphine (0.2 mg/kg) + ibuprofen (10 mg/kg) (morphine + ibuprofen) or morphine (0.2 mg/kg) + placebo of ibuprofen or ibuprofen (10 mg/kg) + placebo of morphine. Primary outcome was children with VAS pain score below 30 mm at 60 minutes postmedication administration.

RESULTS: A total of 501 participants were enrolled and 456 were included in primary analyses (morphine + ibuprofen = 177; morphine = 188; ibuprofen = 91). Only 29.9% (morphine + ibuprofen), 29.3% (morphine), and 33.0% (ibuprofen) of participants achieved the primary outcome (P = .81). Mean VAS pain reduction at 60 minutes were -18.7 (95% confidence interval [CI]: -21.9 to -16.6) (morphine + ibuprofen), -17.0 (95% CI: -20.0 to -13.9) (morphine), -18.6 (95% CI: -22.9 to -14.2) (ibuprofen) (P = .69). Children in the morphine + ibuprofen group (P less than .001) and in the morphine group (P less than .001) experienced more side effects than those in the ibuprofen group. No serious adverse event was reported.

CONCLUSIONS: Combination of morphine with ibuprofen did not provide adequate pain relief for children with MSK-I in the ED. None of the study medication provided an optimal pain management because most of children did not reach a mild pain score

B. Association of Time to Treatment with Short-term Outcomes for Pediatric Patients with Refractory Convulsive Status Epilepticus.

Gaínza-Lein M, et al. JAMA Neurol. 2018 Jan 22 [Epub ahead of print]

IMPORTANCE: Treatment delay for seizures can lead to longer seizure duration. Whether treatment delay is associated with major adverse outcomes, such as death, remains unknown.

OBJECTIVE: To evaluate whether untimely first-line benzodiazepine treatment is associated with unfavorable short-term outcomes.

DESIGN, SETTING, AND PARTICIPANTS: This multicenter, observational, prospective cohort study included 218 pediatric patients admitted between June 1, 2011, and July 7, 2016, into the 11 tertiary hospitals in the United States within the Pediatric Status Epilepticus Research Group. Patients, ranging in age from 1 month to 21 years, with refractory convulsive status epilepticus (RCSE) that did not stop after the administration of at least 2 antiseizure medications were included. Patients were divided into 2 cohorts: those who received the first-line benzodiazepine treatment in less than 10 minutes and those who received it 10 or more minutes after seizure onset (untimely). Data were collected and analyzed from June 1, 2011, to July 7, 2016.

MAIN OUTCOMES AND MEASURES: The primary outcome was death during the related hospital admission. The secondary outcome was the need for continuous infusion for seizure termination. Multivariate analysis of mortality controlled for structural cause, febrile RCSE, age, and previous neurological history (including previous RCSE events). Use of continuous infusions was additionally adjusted for generalized RCSE, continuous RCSE, and 5 or more administrations of antiseizure medication.

RESULTS: A total of 218 patients were included, among whom 116 (53.2%) were male and the median (interquartile range) age was 4.0 (1.2-9.6) years. The RCSE started in the prehospital setting for 139 patients (63.8%). Seventy-four patients (33.9%) received their first-line benzodiazepine treatment in less than 10 minutes, and 144 (66.1%) received untimely first-line benzodiazepine treatment. Multivariate analysis showed that patients who received untimely first-line benzodiazepine treatment had higher odds of death (adjusted odds ratio [AOR], 11.0; 95% CI, 1.43 to ∞; P = .02), had greater odds of receiving continuous infusion (AOR, 1.8; 95% CI, 1.01-3.36; P = .047), had longer convulsive seizure duration (AOR, 2.6; 95% CI, 1.38-4.88; P = .003), and had more frequent hypotension (AOR 2.3; 95% CI, 1.16-4.63; P = .02). In addition, the timing of the first-line benzodiazepine treatment was correlated with the timing of the second-line (95% CI, 0.64-0.95; P  less than  .001) and third-line antiseizure medications (95% CI, 0.25-0.78; P  less than  .001).

CONCLUSIONS AND RELEVANCE: Among pediatric patients with RCSE, an untimely first-line benzodiazepine treatment is independently associated with a higher frequency of death, use of continuous infusions, longer convulsion duration, and more frequent hypotension. Results of this study raise the question as to whether poor outcomes could, in part, be prevented by earlier administration of treatment.

C. Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial.

Foster SJ, et al. Lancet Respir Med. 2018 Feb;6(2):97-106.

BACKGROUND: Children of preschool age often have episodes of virus-associated wheeze, and research assessing efficacy of corticosteroids for paediatric wheeze exacerbations is inconclusive.

METHODS: This non-inferiority, randomised, double-blind, placebo-controlled trial was to compare the efficacy of placebo versus oral prednisolone in children aged 24-72 months presenting with virus-associated wheeze at the paediatric emergency department of Princess Margaret Hospital in Perth, WA, Australia. Eligible participants were randomly assigned (1:1) using a computer-generated random number program to receive placebo or prednisolone (1 mg/kg per day) for 3 days. The primary outcome was total length of stay in hospital until ready for discharge. Following an analysis to test the hypothesis that placebo is non-inferior to prednisolone, a post-hoc superiority analysis was done to test the hypothesis that prednisolone was superior to placebo. A non-inferiority margin of 10% was used to establish non-inferiority. Efficacy analyses were on a modified intention-to-treat basis, whereby patients were excluded from the final efficacy analysis if consent was withdrawn, two doses of study drug were vomited, or paperwork was lost. All participants were included in safety analyses. This study is registered with the Australian and New Zealand Clinical Trials Registry, number ACTRN12612000394842.

FINDINGS: Between June 11, 2012, and June 10, 2015, we screened 3727 patients for eligibility. 624 eligible patients were randomly assigned to treatment, and 605 patients were included in the modified intention-to-treat analysis (300 patients from the placebo group, 305 patients from the prednisolone group). The median length of stay until ready for discharge was longer in the placebo group (540 min [IQR 124-971]) than in the prednisolone group (370 min [121-709]); placebo was inferior to prednisolone. In the post-hoc superiority analysis of 605 patients, the unadjusted ratio of geometric mean for length of stay was 0·79 (95% CI 0·64-0·97; p=0·0227) for the prednisolone group relative to the placebo group. No serious adverse events were reported during the study or follow-up period. One child in the placebo group had a non-specific maculopapular rash, which resolved spontaneously. Two children (one from each group) were reported to be hyperactive during follow-up assessments.

INTERPRETATION: Oral prednisolone had a clear benefit over placebo at reducing the length of stay in children presenting to a paediatric emergency department with virus-associated wheeze and was well tolerated.

D. Cerebrospinal Fluid Reference Values for Young Infants Undergoing LP

Thomson J, et al. Pediatrics. 2018 Feb 2 [Epub ahead of print]

OBJECTIVES: To determine age-specific reference values and quantify age-related changes for cerebrospinal fluid (CSF) white blood cell (WBC) counts and protein and glucose concentrations in infants ≤60 days of age.

METHODS: This multicenter, cross-sectional study included infants ≤60 days old with CSF cultures and complete CSF profiles obtained within 24 hours of presentation. Those with conditions suspected or known to cause abnormal CSF parameters (eg, meningitis) and those with a hospital length of stay of greater than 72 hours were excluded. Reference standards were determined for infants ≤28 days of age and 29 to 60 days of age by using the third quartile +1.5 interquartile range for WBC and protein and the first quartile -1.5 interquartile range for glucose. CSF parameter centile curves based on age were calculated by using the LMST method.

RESULTS: A total of 7766 patients were included. CSF WBC counts were higher in infants ≤28 days of age (upper bound: 15 cells/mm3) than in infants 29 to 60 days of age (upper bound: 9 cells/mm3; P less than .001). CSF protein concentrations were higher in infants ≤28 days of age (upper bound: 127 mg/dL) than in infants 29 to 60 days of age (upper bound: 99 mg/dL; P less than .001). CSF glucose concentrations were lower in infants ≤28 days of age (lower bound: 25 mg/dL) than in infants 29 to 60 days of age (lower bound: 27 mg/dL; P less than .001).

CONCLUSIONS: The age-specific CSF WBC count, protein concentration, and glucose concentration reference values identified in this large, multicenter cohort of infants can be used to interpret the results of lumbar puncture in infants ≤60 days of age.

E. Epidemiology of Bacteremia in Febrile Infants Aged 60 Days and Younger.

Powell EC, and PECARN. Ann Emerg Med. 2018 Feb;71(2):211-216.

…CONCLUSION: The prevalence of bacteremia and meningitis among febrile infants 28 days of age and younger is high and exceeds that observed in infants aged 29 to 60 days. E coli and group B streptococcus are the most common bacterial pathogens.

F. Adenosine Administration with a Stopcock Technique Delivers Lower-Than-Intended Drug Doses.

Weberding NT, et al. Ann Emerg Med. 2018 Feb;71(2):220-224.

STUDY OBJECTIVE: Adenosine administration with a stopcock is the recommended treatment for pediatric patients with acute supraventricular tachycardia. Recent reports suggest that many infants do not respond to the first dose of adenosine administered. Our aim is to determine whether administration of adenosine with a stopcock delivers lower-than-expected drug doses in patients weighing less than 10 kg, corresponding to weights of infants.

CONCLUSION: Administration of adenosine through a stopcock delivers doses lower than intended in patients weighing less than 10 kg, which may account for the decreased response of infants to the first dose of adenosine.

G. What Measures Improve Reduction of Intussusception in Pediatric Patients?

Long B, et al. Ann Emerg Med. 2018 Feb;71(2):236-238.

Take-Home Message
Air enema may be superior to liquid enema for successful reduction of intussusception, and dexamethasone intramuscularly as an adjuvant therapy may reduce intussusception recurrence after air or liquid enema. Glucagon with liquid enema versus liquid enema alone did not result in improved intussusception reduction.

5. Blunt Head Trauma in Pts on Blood Thinners

A. Incidence of Delayed Intracranial Hemorrhage in Older Patients After Blunt Head Trauma.

Chenoweth JA, et al, for Sacramento County Prehospital Research Consortium. JAMA Surg. 2018 Feb 14 [Epub ahead of print].

Importance Current guidelines conflict on the management of older adults who have blunt head trauma taking anticoagulant and antiplatelet medications. This is partially due to the limited data comparing patients who are taking these medications with those who are not.

Objective To investigate the incidence of delayed traumatic intracranial hemorrhage in older adults with head trauma, including those taking anticoagulant and antiplatelet medications.

Design, Setting, and Participants This prospective observational cohort study included patients 55 years and older who had blunt head trauma and were transported via emergency medical services between August 1, 2015, and September 30, 2016. The setting was a multicenter study conducted at 11 hospitals in northern California. Patients were excluded if they had traumatic intracranial hemorrhage on the initial cranial computed tomographic scan, did not have a cranial computed tomographic scan performed at the initial emergency department visit, refused consent for a follow-up telephone call, or did not have reliable means of follow-up.

Main Outcome and Measure The primary outcome of this study was the incidence of delayed traumatic intracranial hemorrhage within 14 days of injury. Results Among 859 patients enrolled in the study, the median age was 75 years (interquartile range, 64-85 years), and 389 (45.3%) were male. A total of 343 patients (39.9%) were taking an anticoagulant or antiplatelet medication. Three patients (0.3%; 95% CI, 0.1%-1.0%) had a delayed traumatic intracranial hemorrhage. Of the 3 patients, 1 of 75 patients (1.3%; 95% CI, 0.0%-7.2%) who were taking warfarin sodium alone and 2 of 516 patients (0.4%; 95% CI, 0.1%-1.4%) who were not taking any anticoagulant or antiplatelet medication had a delayed traumatic intracranial hemorrhage. Thirty-nine patients (4.5%; 95% CI, 3.2%-6.2%) were lost to follow-up. Conclusions and

Relevance Overall, the incidence of delayed intracranial hemorrhage in older adults who have blunt head trauma is low, including patients taking an anticoagulant or antiplatelet medication. These findings suggest that routine observation and serial cranial computed tomography may not be necessary in these patients.

B. Association of ICH Among Patients Taking Non-Vitamin K Antagonist vs Vitamin K Antagonist OACs with In-Hospital Mortality.

Inohara T, et al. JAMA. 2018 Jan 25 [Epub ahead of print]

IMPORTANCE: Although non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used to prevent thromboembolic disease, there are limited data on NOAC-related intracerebral hemorrhage (ICH).

OBJECTIVE: To assess the association between preceding oral anticoagulant use (warfarin, NOACs, and no oral anticoagulants [OACs]) and in-hospital mortality among patients with ICH.

DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 141 311 patients with ICH admitted from October 2013 to December 2016 to 1662 Get With The Guidelines-Stroke hospitals.

EXPOSURES: Anticoagulation therapy before ICH, defined as any use of OACs within 7 days prior to hospital arrival.

MAIN OUTCOMES AND MEASURES: In-hospital mortality.

RESULTS: Among 141 311 patients with ICH (mean [SD] age, 68.3 [15.3] years; 48.1% women), 15 036 (10.6%) were taking warfarin and 4918 (3.5%) were taking NOACs preceding ICH, and 39 585 (28.0%) and 5783 (4.1%) were taking concomitant single and dual antiplatelet agents, respectively. Patients with prior use of warfarin or NOACs were older and had higher prevalence of atrial fibrillation and prior stroke. Acute ICH stroke severity (measured by the National Institutes of Health Stroke Scale) was not significantly different across the 3 groups (median, 9 [interquartile range, 2-21] for warfarin, 8 [2-20] for NOACs, and 8 [2-19] for no OACs). The unadjusted in-hospital mortality rates were 32.6% for warfarin, 26.5% for NOACs, and 22.5% for no OACs. Compared with patients without prior use of OACs, the risk of in-hospital mortality was higher among patients with prior use of warfarin (adjusted risk difference [ARD], 9.0% [97.5% CI, 7.9% to 10.1%]; adjusted odds ratio [AOR], 1.62 [97.5% CI, 1.53 to 1.71]) and higher among patients with prior use of NOACs (ARD, 3.3% [97.5% CI, 1.7% to 4.8%]; AOR, 1.21 [97.5% CI, 1.11-1.32]). Compared with patients with prior use of warfarin, patients with prior use of NOACs had a lower risk of in-hospital mortality (ARD, -5.7% [97.5% CI, -7.3% to -4.2%]; AOR, 0.75 [97.5% CI, 0.69 to 0.81]). The difference in mortality between NOAC-treated patients and warfarin-treated patients was numerically greater among patients with prior use of dual antiplatelet agents (32.7% vs 47.1%; ARD, -15.0% [95.5% CI, -26.3% to -3.8%]; AOR, 0.50 [97.5% CI, 0.29 to 0.86]) than among those taking these agents without prior antiplatelet therapy (26.4% vs 31.7%; ARD, -5.0% [97.5% CI, -6.8% to -3.2%]; AOR, 0.77 [97.5% CI, 0.70 to 0.85]), although the interaction P value (.07) was not statistically significant.

CONCLUSIONS AND RELEVANCE: Among patients with ICH, prior use of NOACs or warfarin was associated with higher in-hospital mortality compared with no OACs. Prior use of NOACs, compared with prior use of warfarin, was associated with lower risk of in-hospital mortality.

6. NEJM Essays on Physician Burnout

A. To Care Is Human — Collectively Confronting the Clinician-Burnout Crisis

Dzau VJ, et al. N Engl J Med 2018; 378:312-314.

he ethical principles that guide clinical care — a commitment to benefiting the patient, avoiding harm, respecting patient autonomy, and striving for justice in health care — affirm the moral foundation and deep meaning underlying many clinicians’ view of their profession as a worthy and gratifying calling. It is clear, however, that owing to the growing demands, burdensome tasks, and increasing stress experienced by many clinicians, alarmingly high rates of burnout, depression, and suicide threaten their well-being. More than half of U.S. physicians report significant symptoms of burnout — a rate more than twice that among professionals in other fields. Moreover, we know that the problem starts early. Medical students and residents have higher rates of burnout and depression than their peers who are pursuing nonmedical careers. Nor is the trend limited to physicians: nurses also experience alarming rates of burnout.1 Clinicians are human, and it takes a personal toll on them when circumstances make it difficult to fulfill their ethical commitments and deliver the best possible care.

Burnout — a syndrome characterized by emotional exhaustion and depersonalization (which includes negativity, cynicism, and the inability to express empathy or grief), a feeling of reduced personal accomplishment, loss of work fulfillment, and reduced effectiveness — has serious consequences in terms of both human cost and system inefficiency.1 Nothing puts these consequences into starker relief than the devastating rates of suicide among physicians. As many as 400 U.S. physicians die by suicide every year.2 Nearly every clinician has been touched at some point by such a tragedy.

Not only are clinicians’ lives at risk, so is patient safety. Some studies have revealed links between clinician burnout and increased rates of medical errors, malpractice suits, and health care–associated infections. In addition, clinician burnout places a substantial strain on the health care system, leading to losses in productivity and increased costs. Burnout is independently associated with job dissatisfaction and high turnover rates. In one longitudinal study, the investigators calculated that annual productivity loss in the United States that is attributable to burnout may be equivalent to eliminating the graduating classes of seven medical schools.1 These consequences are unacceptable by any standard. Therefore, we have an urgent, shared professional responsibility to respond and to develop solutions.

Indeed, there is broad recognition in the health care community that the problem of clinician burnout, depression and other mental disorders, and suicide has reached a crisis level. There are many existing efforts by individual organizations, hospitals, training programs, professional societies, and specialties to confront the crisis. But no single organization can address all the issues that will need to be explored and resolved. There is no mechanism for systematically and collectively gathering data on, analyzing, and mitigating the causes of burnout. The problem is not lack of concern, disagreement about the severity or urgency of the crisis, or absence of will to act. Rather, there is a need to coordinate and synthesize the many ongoing efforts within the health care community and to generate momentum and collective action to accelerate progress. Furthermore, any solution will need to involve key influencers beyond the health care community, such as information technology (IT) vendors, payers, regulators, accreditation agencies, policymakers, and patients….

B. Beyond Burnout — Redesigning Care to Restore Meaning and Sanity for Physicians

Wright AA, et al. N Engl J Med 2018; 378:309-311.

…Burnout rates are now twice as high in medicine as in other fields, even after adjustment for factors such as age, sex, level of education, and hours worked in the past week. In 2014, a national survey found that 54% of U.S. physicians reported at least one symptom of burnout: emotional exhaustion, depersonalization, or a diminished sense of personal accomplishment due to work-related stressors. Those in “front-line” specialties, including general internal medicine, family medicine, emergency medicine, and neurology, are at the highest risk.2

“There was this assumption that doctors could take on extra work seamlessly, but now it is crowding out our true work as healers,” notes Sinsky. “Physicians are at the sharp end of the stick for accountability, regulatory issues, and now even data acquisition and entry — it’s too much.”

Shanafelt and others argue that the situation needs to change and that there’s a business case for addressing physician burnout. At the most basic level, physicians with symptoms of burnout are twice as likely to leave an organization as those without such symptoms, and the cost of replacing a physician is estimated to be $500,000 to $1 million, according to a recent report from Atrius Health. This estimate reflects the expenses for physician recruitment, “onboarding” and training, and lost revenue…

Female physicians may be at highest risk, particularly those with heavy clinical loads. A survey of Stanford School of Medicine faculty found that few female faculty members reported “feeling supported” in their career development. The survey prompted the administration to consider novel ways to improve work–life integration and prevent burnout. Stanford piloted a “time bank” to ensure that faculty were rewarded for activities that are rarely recognized by medical centers, such as serving on committees. This program allowed faculty to trade time spent on these activities for in-home support, such as meal delivery and cleaning services, or support at work, including assistance with grant writing and submission. Though this initiative was meant for all physicians and basic scientists, women used these services more frequently than men, and the number of female faculty members who reported “feeling supported” had nearly doubled by the end of the pilot program.

…Whereas past efforts to address burnout have focused on bolstering individuals’ resilience skills, there’s a growing recognition that organizations also need to redesign the way that clinical care is delivered. In 2015, the Department of Family Medicine at the University of Colorado health system instituted a team-based model called ambulatory process excellence, or APEX. Under this system, medical assistants gather data, reconcile medications, set the agenda for patient visits, and identify opportunities to increase preventive care. After they complete this structured process, they share this information with a physician or nurse practitioner and remain in the room to document the visit. When the clinician leaves, the medical assistant provides patient education and health coaching. This arrangement allows physicians and midlevel clinicians to focus on synthesizing data, performing the physical exam, and making medical decisions without distractions.

“The chaos in exam rooms before APEX was akin to texting while driving,” explains Corey Lyon, associate professor at the University of Colorado School of Medicine and medical director of the A.F. Williams Family Medicine Center. “The greatest advantage now is that the computer no longer stands between me and my patients. This allows for deeper thinking and connection.”…

7. Cardiac Standstill: What Do We know?

A. Does Spontaneous Cardiac Motion, Identified With Point-of-Care Echocardiography During Cardiac Arrest, Predict Survival?

April MD, et al. Ann Emerg Med. 2018 Feb;71(2):208-210.

Take-Home Message
Point-of-care echocardiography demonstrating no spontaneous cardiac motion is associated with lower likelihood of return of spontaneous circulation and survival to hospital admission. This may be used to assist with decisionmaking about resuscitation termination.

B. Variability in Interpretation of Cardiac Standstill Among Physician Sonographers.

Hu K, et al. Ann Emerg Med. 2018 Feb;71(2):193-198.

STUDY OBJECTIVE: Cardiac standstill on point-of-care ultrasonography has been widely studied as a marker of prognosis in cardiac arrest. Return of spontaneous circulation has been reported in as few as 0% and as many as 45% of patients with cardiac standstill. When explicitly documented, the definition of cardiac activity in these studies varied from any slight change in echogenicity of the myocardium to any kinetic cardiac activity. We hypothesize that the variability in research definitions of cardiac activity may affect interpretation of video clips of patients in cardiac arrest. The goal of this study is to assess the variability in interpretation of standstill among physician sonographers.

METHODS: We surveyed physician sonographers at 6 conferences held at 3 academic medical centers in the Greater New York area. Survey respondents were allotted 20 seconds per slide to determine whether each of 15 video clips of patients in cardiac arrest were standstill or not. Data were collected anonymously with radio frequency remotes.

RESULTS: There were 127 total participants, including faculty, fellows, and resident physicians specializing in emergency medicine, critical care, and cardiology. There was only moderate interrater agreement among all participants (α=0.47). This lack of agreement persisted across specialties, self-reported training levels, and self-reported ultrasonographic expertise.

CONCLUSION: According to the results of our study, there appears to be considerable variability in interpretation of cardiac standstill among physician sonographers. Consensus definitions of cardiac activity and standstill would improve the quality of cardiac arrest ultrasonographic research and standardize the use of this technology at the bedside.

C. Transesophageal Echocardiography: Guidelines for Point-of-Care Applications in Cardiac Arrest Resuscitation.

Fair J, et al. Ann Emerg Med. 2018 Feb;71(2):201-207.

Cardiac arrest is one of the most challenging patient presentations managed by emergency care providers, and echocardiography can be instrumental in the diagnosis, prognosis, and treatment guidance in these critically ill patients. Transesophageal echocardiography has many advantages over transthoracic echocardiography in a cardiac arrest resuscitation. As transesophageal echocardiography is implemented more widely at the point of care during cardiac arrest resuscitations, guidelines are needed to assist emergency providers in acquiring the equipment and skills necessary to successfully incorporate it into the management of cardiac arrest victims.

8. On Pulmonary Embolism

A. Very Low Prevalence of PE in ED Patients With Syncope.

Costantino G, et al. JAMA Intern Med. 2018 Jan 29 [Epub ahead of print]

IMPORTANCE: Sparse data and conflicting evidence exist on the prevalence of pulmonary embolism (PE) in patients with syncope.

OBJECTIVE: To estimate the prevalence of PE among patients presenting to the emergency department (ED) for evaluation of syncope.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective, observational study analyzed longitudinal administrative data from 5 databases in 4 different countries (Canada, Denmark, Italy, and the United States). Data from all adult patients (aged ≥18 years) who presented to the ED were screened to identify those with syncope codes at discharge. Data were collected from January 1, 2000, through September 30, 2016.

MAIN OUTCOMES AND MEASURES: The prevalence of PE at ED and hospital discharge, identified using codes from the International Classification of Diseases, was considered the primary outcome. Two sensitivity analyses considering prevalence of PE at 90 days of follow-up and prevalence of venous thromboembolism were performed.

RESULTS: A total of 1 671 944 unselected adults who presented to the ED for syncope were included. The prevalence of PE, according to administrative data, ranged from 0.06% (95% CI, 0.05%-0.06%) to 0.55% (95% CI, 0.50%-0.61%) for all patients and from 0.15% (95% CI, 0.14%-0.16%) to 2.10% (95% CI, 1.84%-2.39%) for hospitalized patients. The prevalence of PE at 90 days of follow-up ranged from 0.14% (95% CI, 0.13%-0.14%) to 0.83% (95% CI, 0.80%-0.86%) for all patients and from 0.35% (95% CI, 0.34%-0.37%) to 2.63% (95% CI, 2.34%-2.95%) for hospitalized patients. Finally, the prevalence of venous thromboembolism at 90 days ranged from 0.30% (95% CI, 0.29%-0.31%) to 1.37% (95% CI, 1.33%-1.41%) for all patients and from 0.75% (95% CI, 0.73%-0.78%) to 3.86% (95% CI, 3.51%-4.24%) for hospitalized patients.

CONCLUSIONS AND RELEVANCE: Pulmonary embolism was rarely identified in patients with syncope. Although PE should be considered in every patient, not all patients should undergo evaluation for PE.

Related study: Frizell A, et al. Prevalence of PE in patients presenting to the ED with syncope. Am J Emerg Med 2018;36:253-6. Abstract:

B. Effect of the PE Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk ED Patients: The PROPER Randomized Clinical Trial

Freund Y, et al. JAMA. 2018 Feb 13;319(6):559-566..

IMPORTANCE: The safety of the pulmonary embolism rule-out criteria (PERC), an 8-item block of clinical criteria aimed at ruling out pulmonary embolism (PE), has not been assessed in a randomized clinical trial.

OBJECTIVE: To prospectively validate the safety of a PERC-based strategy to rule out PE.

DESIGN, SETTING, AND PATIENTS: A crossover cluster-randomized clinical noninferiority trial in 14 emergency departments in France. Patients with a low gestalt clinical probability of PE were included from August 2015 to September 2016, and followed up until December 2016.

INTERVENTIONS: Each center was randomized for the sequence of intervention periods. In the PERC period, the diagnosis of PE was excluded with no further testing if all 8 items of the PERC rule were negative.

MAIN OUTCOMES AND MEASURES: The primary end point was the occurrence of a thromboembolic event during the 3-month follow-up period that was not initially diagnosed. The noninferiority margin was set at 1.5%. Secondary end points included the rate of computed tomographic pulmonary angiography (CTPA), median length of stay in the emergency department, and rate of hospital admission.

RESULTS: Among 1916 patients who were cluster-randomized (mean age 44 years, 980 [51%] women), 962 were assigned to the PERC group and 954 were assigned to the control group. A total of 1749 patients completed the trial. A PE was diagnosed at initial presentation in 26 patients in the control group (2.7%) vs 14 (1.5%) in the PERC group (difference, 1.3% [95% CI, -0.1% to 2.7%]; P = .052). One PE (0.1%) was diagnosed during follow-up in the PERC group vs none in the control group (difference, 0.1% [95% CI, -∞ to 0.8%]). The proportion of patients undergoing CTPA in the PERC group vs control group was 13% vs 23% (difference, -10% [95% CI, -13% to -6%]; P  less than.001). In the PERC group, rates were significantly reduced for the median length of emergency department stay (mean reduction, 36 minutes [95% CI, 4 to 68]) and hospital admission (difference, 3.3% [95% CI, 0.1% to 6.6%]).

CONCLUSIONS AND RELEVANCE: Among very low-risk patients with suspected PE, randomization to a PERC strategy vs conventional strategy did not result in an inferior rate of thromboembolic events over 3 months. These findings support the safety of PERC for very low-risk patients presenting to the emergency department.

9. Geriatric Emergency Medicine

A. An ED Observation Unit Is a Feasible Setting for Multidisciplinary Geriatric Assessments in Compliance with the Geriatric ED Guidelines

Southerland LT, et al. Acad Emerg Med. 2018 Jan;25(1):76-82.

BACKGROUND: The Geriatric Emergency Department (ED) Guidelines recommend providing multidisciplinary geriatric assessment in the ED, but these assessments can be difficult to coordinate and may prolong length of stay. Patients who need longer than a typical ED stay can be placed in an ED observation unit (Obs Unit). We investigated the effects of offering multidisciplinary assessments for ED patients in an Obs Unit.

METHODS: Evaluation by a geriatric hospital consultation team, physical therapist, case manager, and/or pharmacist was made available to all Obs Unit patients. Use of any or all of these ancillary consult services could be requested by the Obs Unit physician. A retrospective chart review of random older adult Obs Unit patients was done to assess rates of consult use and interventions by these consulting teams. All patients ≥ 65 years old in our institutional review board-approved, monthly Obs Unit quality database from October 2015 through March 2017 were included.

RESULTS: Our quality database included 221 older patients over 18 months. The mean (±SD) age was 73.3 (±6.8) years (range = 65-96 years) and 55.2% were women. The mean (±SD) observation length of stay was 14.7 (±6.5) hours. The majority (74.3%) were discharged from the Obs Unit and 72-hour ED recidivism was 3.6%. Overall, at least one of the multidisciplinary consultant services were requested in 40.3% of patients (n = 89). Additional interventions or services were recommended in 80.0% of patients evaluated by physical therapy (32 of 40 patients), 100% of those evaluated by a pharmacist (five of five patients), 38% of those evaluated by case management (27 of 71 patients), and 100% of those evaluated by a geriatrician (eight of eight patients). Only 5.4% (n = 12) of patients were placed in observation specifically for multidisciplinary assessment; these patients had a mean (±SD) length of stay of 12.2 (±5) hours and an admission rate of 41.7%.

CONCLUSIONS: Incorporating elements of multidisciplinary geriatric assessment for older patients is feasible within an observation time frame and resulted in targeted interventions. An Obs Unit is a reasonable setting to offer services in compliance with the Geriatric ED Guidelines.

B.  ED Innovations: Transitional Care Nurses Reduce Hospital Admissions for Elderly Pts

Hwang U, et al. J Am Geriatr Soc. 2018 Jan 10 [Epub ahead of print].

OBJECTIVES: To examine the effect of an emergency department (ED)-based transitional care nurse (TCN) on hospital use.

DESIGN: Prospective observational cohort.

SETTING: Three U.S. (NY, IL, NJ) EDs from January 1, 2013, to June 30, 2015.

PARTICIPANTS: Individuals aged 65 and older in the ED (N = 57,287).

INTERVENTION: The intervention was first TCN contact. Controls never saw a TCN during the study period.

MEASUREMENTS: We examined sociodemographic and clinical characteristics associated with TCN use and outcomes. The primary outcome was inpatient admission during the index ED visit (admission on Day 0). Secondary outcomes included cumulative 30-day admission (any admission on Days 0-30) and 72-hour ED revisits.

RESULTS: A TCN saw 5,930 (10%) individuals, 42% of whom were admitted. After accounting for observed selection bias using entropy balance, results showed that when compared to controls, TCN contact was associated with lower risk of admission (site 1: -9.9% risk of inpatient admission, 95% confidence interval (CI) = -12.3% to -7.5%; site 2: -16.5%, 95% CI = -18.7% to -14.2%; site 3: -4.7%, 95% CI = -7.5% to -2.0%). Participants with TCN contact had greater risk of a 72-hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7-2.3%; site 2: 1.4%, 95% CI = 0.7-2.1%). Risk of any admission within 30 days of the index ED visit also remained lower for TCN patients at both these sites (site 1: -7.8%, 95% CI = -10.3% to -5.3%; site 2: -13.8%, 95% CI = -16.1% to -11.6%).

CONCLUSION: Targeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission.

10. Improving ED Atrial Fibrillation Management

A. Improving Stroke Prevention

Vinson DR, et al, with the KP CREST Network. Thromboprophylaxis for High-risk AF/FL Discharged from the ED. West J Emerg Med. 2018 Feb 12 [Epub ahead of print].

Background: Many patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis. We examined anticoagulant prescribing within 30 days of receiving dysrhythmia care for nonvalvular AF/FL in the emergency department (ED).

Methods: This prospective study included non-anticoagulated adults at high-risk for ischemic stroke (ATRIA score ≥7) who received emergency AF/FL care and were discharged home from seven community EDs between May 2011 and August 2012. We characterized oral anticoagulant prescribing patterns and identified predictors of receiving anticoagulants within 30 days of the index ED visit. We also describe documented reasons for withholding anticoagulation.

Results: Of 312 eligible patients, 128 (41.0%) were prescribed anticoagulation at ED discharge or within 30 days. Independent predictors of anticoagulation included younger age (adjusted odds ratio [aOR] 0.89 per year, 95% CI 0.82-0.96), ED cardiology consultation (aOR 1.89, 95% CI 1.10-3.23), and failure of sinus restoration by time of ED discharge (aOR 2.65, 95% CI 1.35-5.21). Reasons for withholding anticoagulation at ED discharge were documented in 139 of 227 cases (61.2%), the most common of which were deferring the shared decision-making process to the patient’s outpatient provider, perceived bleeding risk, patient refusal, and restoration of sinus rhythm.

Conclusions: Approximately 40% of non-anticoagulated AF/FL patients at high risk for stroke who presented for emergency dysrhythmia care were prescribed anticoagulation within 30 days. Physicians were less likely to anticoagulate older patients and those with ED sinus restoration. Opportunities exist to improve rates of thromboprophylaxis in this high-risk population.

Physician misunderstandings were prevalent. Two common ones:
  • Older pts were less commonly treated because physicians were more worried about bleeds than strokes—a sizable miscalculation. Strokes are far more dangerous than bleeds in the older anticoagulated AF population.
  • High-risk pts who converted in the ED were less likely to receive stroke prevention medication, as though paroxysmal AF that flipped back into NSR significantly reduced stroke risk. It doesn’t. Intermittent AF warrants thromboprophylaxis as much as persistent AF.

For the discussion, see the full-text (free):

B. Improving ED Rate Reduction

de Leon E, et al. Impact of standardizing management of atrial fibrillation with rapid heart rate in the emergency department. Perm J. 2018;22:17-049.

Context: There is substantial variation in the emergency treatment of atrial fibrillation with tachycardia. A standardized treatment approach at an academic center decreased admissions without adverse outcomes, but this approach has not been evaluated in a community Emergency Department (ED).

Objective: To evaluate the implementation of a standardized treatment guideline for patients with atrial fibrillation and a rapid heart rate in a community ED.

Design: An observational pre-/postimplementation (August 2013 to July 2014 and August 2014 to July 2015, respectively) study at a community ED. The standardized treatment guideline encouraged early oral treatment with rate control medication, outpatient echocardiogram, and early follow-up. A multiple logistic regression model adjusting for patient characteristics was generated to investigate the association between the intervention and ED discharge rate.

Main Outcome Measures: The primary measure was ED discharge. Secondary measures included stroke or death, ED return visit, hospital readmission, length of stay, and use of oral rate control medications.

Results: A total of 199 (104 pre/95 post) ED encounters were evaluated. The ED discharge rate increased 14% after intervention (57.7% to 71.6%, p = 0.04), and use of rate control medications increased by 19.4% (p less than 0.01). Adjusted multivariate results showed a nearly 2-fold likelihood of ED discharge after guideline implementation (odds ratio = 1.97, 95% confidence interval = 1.07-3.63). Length of stay, return visits, and hospital readmissions were similar.

Conclusion: A standardized approach to ED patients with atrial fibrillation and tachycardia is associated with a decrease in hospital admissions without adversely affecting patient safety.

11. Images in Clinical Practice

Calcified Spleen and Gallstones

Creutzfeldt–Jakob Disease

ECG Changes in Hypothermia
A 76-year-old woman with a history of dementia and coronary heart disease was brought to the emergency department after she had been found lying outdoors for an undetermined period; her core body temperature was 26°C (78.8°F) at presentation. An electrocardiogram showed prominent Osborn waves, also known as J waves (Panel A, arrows), along with prolonged QRS duration and corrected QT interval.

Herpetic Whitlow

Phlegmasia Cerulea Dolens with Compartment Syndrome
An 81-year-old man with hypertension presented to the emergency department with pain and swelling of the left thigh and lower leg that had developed during the previous several hours. He had no history of recent surgery or trauma and no known personal or family history of clotting disorders. The left lower leg was tender, cold, and swollen (Panel A), and the left dorsalis pedis pulse was not palpable.

Man With Bumps on His Shin

Man With Chest Pain and Lump in Neck

Male With Sore Throat

Infant With a Diffuse Rash and a Fever

Hyperactive Child With Chest Pain

Elderly Woman With Decreased Right-Sided Vision

Adolescent With a Non-Healing Thigh Injury

Man With Rash

Child With Diffuse Bullous Rash

Adult Male With Chest Pain After a Fall

Man With Abdominal Pain

Elderly Woman With Abdominal Pain

Young Boy With Roughening in the Inner Eyelids

12. Computer-Interpreted ECGs: Benefits and Limitations.

Schläpfer J, Wellens HJ. J Am Coll Cardiol. 2017 Aug 29;70(9):1183-1192.

Computerized interpretation of the electrocardiogram (CIE) was introduced to improve the correct interpretation of the electrocardiogram (ECG), facilitating health care decision making and reducing costs. Worldwide, millions of ECGs are recorded annually, with the majority automatically analyzed, followed by an immediate interpretation. Limitations in the diagnostic accuracy of CIE were soon recognized and still persist, despite ongoing improvement in ECG algorithms. Unfortunately, inexperienced physicians ordering the ECG may fail to recognize interpretation mistakes and accept the automated diagnosis without criticism. Clinical mismanagement may result, with the risk of exposing patients to useless investigations or potentially dangerous treatment. Consequently, CIE over-reading and confirmation by an experienced ECG reader are essential and are repeatedly recommended in published reports. Implementation of new ECG knowledge is also important. The current status of automated ECG interpretation is reviewed, with suggestions for improvement.

Commentary: How Computer-Interpreted ECGs May Lead to Errors

By Amal Mattu, MD. Medscape, Nov 28, 2017

ECG was invented more than 100 years ago.[1] Despite many technical advances in the field of emergency cardiology, the basic 12-lead ECG still remains a cornerstone test in the acute diagnosis of many types of cardiac conditions, both acute and chronic.

Automated ECG analysis was initiated in the 1950s in an attempt to assist providers who had less training in ECG interpretation.[1] Unfortunately, despite improvements in the automated interpretations over the past 60 years, computer ECG interpretations remain far from perfect. Despite the common teaching that we should not trust the computer interpretations, many healthcare providers still rely heavily on these interpretations in their clinical practice.

The following review provides some excellent information regarding the benefits and limitations of the computer interpretation programs.

Study Summary
  • The authors reviewed technical specifications about the various computer programs and also numerous articles regarding accuracy data on the various algorithms. The following is a list of key points they made.
  • There is no international accepted standard for computer interpretations. As a result, significant variability exists among interpretations from different manufacturers' algorithms.
  • Direct comparative evaluations of the various commercially available computer-interpreted ECG (CIE) programs has never been performed.
  • A 1991 study of nine CIE programs versus eight cardiologists demonstrated consistently lower accuracy among the CIEs compared with the cardiologists, and also (surprisingly) significant variation in accuracy among the various programs.[2]
  • CIE programs have a frequent tendency to overcall atrial fibrillation, especially in elderly persons, potentially leading to inappropriate administration of harmful medications.
  • CIE programs have a tendency to double-count the rate due to large T-waves (eg, in the setting of hyperkalemia).
  • CIE programs are particularly inaccurate in diagnosing pacemaker rhythms.
  • CIE programs demonstrate wide variations in the false-positive (0%-42%) and false-negative (22%-42%) rates of diagnosis of ST-segment myocardial infarction; therefore, it is not recommended that CIEs be used as a sole means of activation of the cardiac catheterization lab.
  • CIE programs frequently tend to underestimate the QT interval, especially in the presence of artifact or improperly placed leads.
  • The authors cite a 2008 study indicating that "It has been roughly estimated that [CIE] misdiagnoses may account for up to 10,000 adverse effects or avoidable deaths worldwide annually."[3]
  • The authors summarize, "Computer-based analysis of the ECG may lead to erroneous diagnosis with useless, inappropriate, or even dangerous care of the patient."

This article sheds some much-needed light on the true accuracy of CIE programs. Although these programs may help providers who are inexperienced in ECG interpretation, they appear to decrease the accuracy of experienced providers by frequently providing a false sense of security with benign interpretations and also by encouraging less scrutiny of the ECG. I truly believe that if the computer interpretations were removed, providers would pay closer attention to the ECG, resulting in more accurate interpretations and fewer errors. I also believe that our trainees would feel compelled to work harder at their ECG interpretation skills if the computer interpretations were removed.

During the past 15 years, I've seen at least a half-dozen malpractice cases in which the computer interpretation simply indicated "nonspecific" findings on ECGs that demonstrated fairly obvious ischemia. In each of these cases, the treating physician was misled by the computer, and only in retrospect, too late, did the physician recognize the ischemic findings. These cases are typically nearly impossible to defend.

ECG interpretation is a life-saving skill. Proficiency is a must for us all. We must exercise extreme caution regarding the utility of these CIE programs and gain enough skill and confidence to avoid using them entirely.

13. “Sometimes You Feel Like the Freak Show”: A Qualitative Assessment of Emergency Care Experiences Among Trans and Gender Non-Conforming Patients

Samuels EA, et al. Ann Emerg Med. 2018;71(2):170–182.e1

STUDY OBJECTIVE: Transgender, gender-variant, and intersex (trans) people have decreased access to care and poorer health outcomes compared with the general population. Little has been studied and documented about such patients' emergency department (ED) experiences and barriers to care. Using survey and qualitative research methods, this study aims to identify specific areas for improvement and generate testable hypotheses about the barriers and challenges for trans individuals needing acute care.

METHODS: A survey and 4 focus groups were conducted with trans individuals older than 18 years who had been to an ED in the last 5 years. Participants were recruited by trans e-mail listservs; outreach to local trans organizations; and lesbian, gay, bisexual, and transgender periodical advertisements. The interview guide was reviewed by qualitative research and trans health content experts. Deidentified participant demographic information was collected with a standardized instrument. All discussions were captured on digital audio recorders and professionally transcribed. Interview coding and thematic analysis were conducted with a grounded theory approach.

RESULTS: Among 32 participants, 71.9% were male identified and 78.1% were white. Nearly half (43.8%) reported avoiding the ED when they needed acute care. The factors that had the greatest influence on ED avoidance were fear of discrimination, length of wait, and negative previous experiences. There were 4 overarching discussion themes: system structure, care competency, discrimination and trauma, and avoidance of emergency care. Improvement recommendations focused on staff and provider training about gender and trans health, assurance of private gender identity disclosure, and accurate capture of sex, gender, and sexual orientation information in the electronic medical record.

CONCLUSION: Efforts to improve trans ED experiences should focus on provider competency and communication training, electronic medical record modifications, and assurance of private means for gender disclosure. Future research directions include quantifying the frequency of care avoidance, the effect of avoidance on trans patient morbidity and mortality, and comparing ED patient outcomes by gender identity. Further research with increased inclusion of transwomen and people of color is needed to identify themes that may not have been raised in this preliminary investigation.

14. Differences Between Snakebites with Concomitant Use of Alcohol or Drugs and Single Snakebites.

Schulte J, et al. South Med J. 2018 Feb;111(2):113-117.

OBJECTIVES: Published reports have suggested that the concurrent use of alcohol or drugs occurs among some snakebite victims, but no national assessment of such data exists.

METHODS: We used data from US poison control centers collected during telephone calls in calendar years 2000-2013 to compare snake envenomations with concomitant use of drugs, alcohol, or both to snakebites lacking such use.

RESULTS: A total of 608 snakebites with 659 instances of concomitant alcohol/drug use were reported, which represent approximately 1% of 92,751 snakebites reported to US poison control centers. An annual mean of 48 snakebites with concomitant use of alcohol/drugs was reported, compared with a mean of 6625 snakebites per year with no concomitant use of alcohol/drugs. Most cases involved men, peaked during the summer months, and involved copperheads or rattlesnakes, which mirrored overall trends. Snakebite victims who also used alcohol/drugs were more likely than victims with only a snakebite reported to be bitten by rattlesnakes, to be admitted to the hospital, and die. Alcohol was the most common reported concomitant substance, but other substances were reported.

CONCLUSIONS: Snakebites with concomitant use of alcohol/drugs are uncommon, accounting for approximately 1% of the snakebite envenomations reported annually to US poison control centers; however, snakebite victims also reporting alcohol/drug use are more likely to be bitten by rattlesnakes, be admitted to a healthcare facility, and die.

15. Sepsis Research

A. No Evidence Underpinning the U.S. Government–Mandated Hemodynamic Interventions for Sepsis: A Systematic Review

Pepper DJ, et al. Ann Intern Med. 2018 Feb 20 [Epub ahead of print]

Background: The Severe Sepsis and Septic Shock Early Management Bundle (SEP-1), the sepsis performance measure introduced by the Centers for Medicare & Medicaid Services (CMS), requires up to 5 hemodynamic interventions, as many as 141 tasks, and 3 hours to document for a single patient.

Purpose: To evaluate whether moderate- or high-level evidence shows that use of SEP-1 or its hemodynamic interventions improves survival in adults with sepsis.

Data Sources: PubMed, Embase, Scopus, Web of Science, and from inception to 28 November 2017 with no language restrictions.

Study Selection: Randomized and observational studies of death among adults with sepsis who received versus those who did not receive either the entire SEP-1 bundle or 1 or more SEP-1 hemodynamic interventions, including serial lactate measurements; a fluid infusion of 30 mL/kg of body weight; and assessment of volume status and tissue perfusion with a focused examination, bedside cardiovascular ultrasonography, or fluid responsiveness testing.

Data Extraction: Two investigators independently extracted study data and assessed each study's risk of bias; 4 authors rated level of evidence by consensus using CMS criteria. High- or moderate-level evidence required studies to have no confounders and low risk of bias.

Data Synthesis: Of 56 563 references, 20 studies (18 reports) met inclusion criteria. One single-center observational study reported lower in-hospital mortality after implementation of the SEP-1 bundle. Sixteen studies (2 randomized and 14 observational) reported increased survival with serial lactate measurements or 30-mL/kg fluid infusions. None of the 17 studies were free of confounders or at low risk of bias. In 3 randomized trials, fluid responsiveness testing did not alter survival.

Limitation: Few trials, poor-quality and confounded studies, and no studies (with survival outcomes) of the focused examination or bedside cardiovascular ultrasonography.

Conclusion: No high- or moderate-level evidence shows that SEP-1 or its hemodynamic interventions improve survival in adults with sepsis.

B. Prognostic Accuracy of the Quick Sequential Organ Failure Assessment for Mortality in Patients with Suspected Infection: A Systematic Review and Meta-analysis.

Fernando SM, et al. Ann Intern Med. 2018 Feb 20;168(4):266-275.

BACKGROUND: The quick Sequential Organ Failure Assessment (qSOFA) has been proposed for prediction of mortality in patients with suspected infection.

PURPOSE: To summarize and compare the prognostic accuracy of qSOFA and the systemic inflammatory response syndrome (SIRS) criteria for prediction of mortality in adult patients with suspected infection.

DATA SOURCES: Four databases from inception through November 2017.

STUDY SELECTION: English-language studies using qSOFA for prediction of mortality (in-hospital, 28-day, or 30-day) in adult patients with suspected infection in the intensive care unit (ICU), emergency department (ED), or hospital wards.

DATA EXTRACTION: Two investigators independently extracted data and assessed study quality using standard criteria.

DATA SYNTHESIS: Thirty-eight studies were included (n = 385 333). qSOFA was associated with a pooled sensitivity of 60.8% (95% CI, 51.4% to 69.4%) and a pooled specificity of 72.0% (CI, 63.4% to 79.2%) for mortality. The SIRS criteria were associated with a pooled sensitivity of 88.1% (CI, 82.3% to 92.1%) and a pooled specificity of 25.8% (CI, 17.1% to 36.9%). The pooled sensitivity of qSOFA was higher in the ICU population (87.2% [CI, 75.8% to 93.7%]) than the non-ICU population (51.2% [CI, 43.6% to 58.7%]). The pooled specificity of qSOFA was higher in the non-ICU population (79.6% [CI, 73.3% to 84.7%]) than the ICU population (33.3% [CI, 23.8% to 44.4%]).

LIMITATION: Potential risk of bias in included studies due to qSOFA interpretation and patient selection.

CONCLUSION: qSOFA had poor sensitivity and moderate specificity for short-term mortality. The SIRS criteria had sensitivity superior to that of qSOFA, supporting their use for screening of patients and as a prompt for treatment initiation.

16. Beware the Danger Lurking Under the Shroud of Alcohol

Sheehy M, et al. Ann Emerg Med 2018;71(3):289-91.

Annals Case
An alcohol-dependent patient well known to your emergency department (ED) presents with…drumroll please…alcohol intoxication. A Good Samaritan called 911 after finding the patient asleep on a park bench. His chart is overflowing with ED visits for alcohol intoxication and usually conclude with an early-morning discharge. His vital signs are pulse rate 98 beats/min, respiratory rate 18 breaths/min, blood pressure 156/76 mm Hg, and oxygen saturation 97% on room air. On examination, he appears intoxicated—alcohol on his breath, opens his eyes and speaks confused words to painful stimuli—and is protecting his airway. There are no signs of acute head trauma or other injury.

So what’s the plan? Does this patient need laboratory tests, head computed tomography (CT), or withdrawal prevention?

You have probably treated a patient like this recently. The statistics sure say you have. Rates of alcohol intoxication ED visits are increasing out of proportion to overall ED visits.1 Average blood alcohol concentrations (BACs) are increasing too!2 So patients are getting more intoxicated more frequently. Although many simply require observation until clinically sober, with an eventual turkey sandwich, badness may lurk beneath the shroud of alcohol…and it may be hard to identify on initial evaluation.

Klein et al3 looked for badness retrospectively in 31,364 cases of low-risk acute alcohol intoxication. One percent of their study cohort, or 325 patients, required critical care resources while in the ED. Included patients were deemed to be at low risk according to triage nurse and emergency physician assessment after a mandatory alcohol level and fingerstick glucose-level test.3 The rate of badness, therefore, among all comers with presumed alcohol abuse is undoubtedly higher; hence, the common refrain, “Alcoholics were put on this earth to humble emergency physicians.”

What can we learn from this study? Indicators for potential badness were abnormal vital signs, hypoglycemia, or need for chemical sedation. Although these red flags may seem obvious in hindsight, they can be easily dismissed with seemingly benign explanations. Tachycardia and hypotension may be attributed to dehydration, a coingestion, or anxiety, especially when anchored on a diagnosis of alcohol intoxication. This article reminds us to always consider other causes for the patient’s altered mental status. And make sure there is a full set of vital signs recorded. What was our example patient’s temperature? Oh, it wasn’t taken?!

17. Association of Clinician Denial of Patient Requests with Patient Satisfaction.

Jerant A, et al. JAMA Intern Med. 2018 Jan 1;178(1):85-91.

IMPORTANCE: Prior studies suggesting clinician fulfillment or denial of requests affects patient satisfaction included limited adjustment for patient confounders. The studies also did not examine distinct request types, yet patient expectations and clinician fulfillment or denial might vary among request types.

OBJECTIVE: To examine how patient satisfaction with the clinician is associated with clinician denial of distinct types of patient requests, adjusting for patient characteristics.

DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional observational study of 1319 outpatient visits to family physicians (n = 56) by 1141 adults at one Northern California academic health center.

MAIN OUTCOMES AND MEASURES: We used 6 Consumer Assessment of Healthcare Providers and Systems Clinician and Group Adult Visit Survey items to measure patient satisfaction with the visit physician. Standardized items were averaged to form the satisfaction score (Cronbach α = 0.80), which was then percentile-transformed. Seven separate linear mixed-effects models examined the adjusted mean differences in patient satisfaction percentile associated with denial of each of the following requests (if present)-referral, pain medication, antibiotic, other new medication, laboratory test, radiology test, or other test-compared with fulfillment of the respective requests. The models adjusted for patient sociodemographics, weight, health status, personality, worry over health, prior visit with clinician, and the other 6 request categories and their dispositions.

RESULTS: The mean (SD) age of the 1141 patients was 45.6 (16.1) years, and 902 (68.4%) were female. Among 1319 visits, 897 (68.0%) included at least 1 request; 1441 (85.2%) were fulfilled. Requests by category were referral, 294 (21.1%); pain medication, 271 (20.5%); antibiotic, 107 (8.1%); other new medication, 271 (20.5%); laboratory test, 448 (34.0%); radiology test, 153 (11.6%); and other tests, 147 (11.1%). Compared with fulfillment of the respective request type, clinician denials of requests for referral, pain medication, other new medication, and laboratory test were associated with worse satisfaction (adjusted mean percentile differences, -19.75 [95% CI, -30.75 to -8.74], -10.72 [95% CI, -19.66 to -1.78], -20.36 [95% CI, -29.54 to -11.18], and -9.19 [95% CI, -17.50 to -0.87]), respectively.

CONCLUSIONS AND RELEVANCE: Clinician denial of some types of requests was associated with worse patient satisfaction with the clinician, but not for others, when compared with fulfillment of the requests. In an era of patient satisfaction-driven compensation, the findings suggest the need to train clinicians to deal effectively with requests, potentially enhancing patient and clinician experiences.

18. Pain Reduction in Trauma Patients

A. Acetaminophen equal to NSAIDs in Acute Musculoskeletal Trauma: A Multicenter, Double-Blind, RCT

Ridderikhof ML, et al. Ann Emerg Med. 2018 Mar;71(3):357-368.e8.

STUDY OBJECTIVE: We determine whether pain treatment with acetaminophen was not inferior to nonsteroidal anti-inflammatory drugs or the combination of both in minor musculoskeletal trauma.

METHODS: The Paracetamol or NSAIDs in Acute Musculoskeletal Trauma Study was a double-blind, randomized, clinical trial conducted in 2 general practices and 2 emergency departments in the Netherlands. A total of 547 adults, aged 18 years and older, with acute blunt minor musculoskeletal extremity trauma were randomly assigned in a 1:1:1 ratio to acetaminophen 4,000 mg/day, diclofenac 150 mg/day, or acetaminophen 4,000 mg/day+diclofenac 150 mg/day during 3 consecutive days. Patients, health care staff, and outcome assessors were blinded for treatment allocation. Follow-up for each patient was 30 days. Primary outcome measures were between-group differences in mean numeric rating scale (NRS) pain scores in rest and with movement at 90 minutes after initial drug administration compared with baseline pain scores with a predefined noninferiority margin of 0.75 NRS points. Secondary outcomes included NRS pain scores during 3 consecutive days and need for additional analgesia.

RESULTS: One hundred eighty-two patients were treated with acetaminophen, 183 with diclofenac, and 182 with combination treatment. Intention-to-treat analysis revealed mean NRS reduction in rest -1.23 (95% confidence interval [CI] -1.50 to -0.95) and -1.72 (95% CI -2.01 to -1.44) with movement, both for acetaminophen at 90 minutes compared with baseline. Pairwise comparison in rest with diclofenac showed a difference of -0.027 (97.5% CI -0.45 to 0.39) and -0.052 (97.5% CI -0.46 to 0.36) for combination treatment. With movement, these numbers were -0.20 (97.5% CI -0.64 to 0.23) and -0.39 (97.5% CI -0.80 to 0.018), respectively. All differences were well below the predefined noninferiority margin.

CONCLUSION: Pain treatment with acetaminophen was not inferior to that with diclofenac or the combination of acetaminophen and diclofenac in acute minor musculoskeletal extremity trauma, both in rest and with movement.

B. How Effective Is a Regional Nerve Block for Treating Pain Associated with Hip Fractures?

Gottlieb M, et al. Ann Emerg Med. 2018 Mar;71(3):378-380.

Take-Home Message
Regional nerve blockade reduces pain on movement, risk of pneumonia, and time to first mobilization among patients with hip fractures with no major complications.

19. Quick Lit Reviews

From BMJ’s Rapid Recommendations

A. Antibiotics after incision and drainage for uncomplicated skin abscesses: a clinical practice guideline

What you need to know
For uncomplicated skin abscesses, we suggest using trimethoprim-sulfamethoxazole (TMP-SMX) or clindamycin in addition to incision and drainage rather than incision and drainage alone, and emphasise the need for shared decision making

TMP-SMX or clindamycin modestly reduces pain and treatment failure and probably reduces abscess recurrence, but increases the risk of adverse effects including nausea and diarrhoea

We suggest TMP-SMX rather than clindamycin because TMP-SMX has a lower risk of diarrhoea

Cephalosporins in addition to incision and drainage are probably not more effective than incision and drainage alone in most settings

From a societal perspective, the modest benefits from adjuvant antibiotics may not outweigh the harms from increased antimicrobial resistance in the community, although this is speculative

Full-text (free) with intelligent graphics:

Related article: Frazee B. Antibiotics for simple skin abscesses: the new evidence in perspective. Emerg Med J. 2018 Jan 24 [Epub ahead of print]. Link (subscription required):

B. Corticosteroids for sore throat: a clinical practice guideline

What you need to know:
Sore throat is one of the most common reasons for primary care appointments, and international guidance varies about whether to use corticosteroids to treat it, but a trial published in April 2017 suggested that costicosteroids might be effective

We make a weak recommendation to use a single dose of oral corticosteroids, in those presenting with acute sore throat, after performing a systematic review of the new evidence in this rapid recommendation publication package

The recommendation is weak and shared decision making is needed because corticosteroids did not help all patient reported outcomes and patients’ preferences varied substantially

Steroids somewhat reduced the severity and duration of pain by one day, but time off school or work was unchanged. Harm seems unlikely with one steroid dose.

The treatment is inexpensive and likely to be offered in the context of a consultation that would have taken place anyway.

Full-text (free) with intelligent graphics:

From Ann Emerg Med

A. Does Prestroke Antiplatelet Therapy Increase the Risk of Symptomatic Intracranial Hemorrhage in Patients Receiving tPA for Acute Ischemic Stroke?

Take home: In patients receiving prestroke aspirin and clopidogrel combination therapy, thrombolysis in acute ischemic stroke is associated with an increased risk of symptomatic intracranial hemorrhage, yet there is no evidence for increased mortality or worse functional outcomes.

B. Do IV Benzodiazepines or Benzodiazepines by an Alternative Route (Nonintravenous) Abort Seizures Faster [in pts without initial IV access]?

Take home: Benzodiazepines by an alternative route abort seizures faster and possess superior efficacy compared with intravenous benzodiazepines in patients without intravenous access.

20. On Being Sued for Malpractice

A. Provider and Practice Factors Associated with Emergency Physicians Being Named in a Malpractice Claim

Carlson JN, et al. Ann Emerg Med 2018;71(2):157–164.e4

Study objective
We examine the association between emergency physician characteristics and practice factors with the risk of being named in a malpractice claim.

We used malpractice claims along with provider, operational, and jurisdictional data from a national emergency medicine group (87 emergency departments [EDs] in 15 states from January 1, 2010, to June 30, 2014) to assess the relationship between individual physician and practice variables and being named in a malpractice claim. Individual and practice factors included years in practice, emergency medicine board certification, visit admission rate, relative value units generated per hour, total patients treated as attending physician of record, working at multiple facilities, working primarily overnight shifts, patient experience data percentile, and state malpractice environment. We assessed the relationship between emergency physician and practice variables and malpractice claims, using logistic regression.

Of 9,477,150 ED visits involving 1,029 emergency physicians, there were 98 malpractice claims against 90 physicians (9%). Increasing total number of years in practice (adjusted odds ratio 1.04; 95% confidence interval 1.02 to 1.06) and higher visit volume (adjusted odds ratio 1.09 per 1,000 visits; 95% confidence interval 1.05 to 1.12) were associated with being named in a malpractice claim. No other factors were associated with malpractice claims.

In this sample of emergency physicians, 1 in 11 were named in a malpractice claim during 4.5 years. Total number of years in practice and visit volume were the only identified factors associated with being named, suggesting that exposure to higher patient volumes and longer practice experience are the primary contributors to malpractice risk.

B. Editorial: Malpractice Claims: It’s a Crapshoot. Time to Stop the Self-Blame and Ask Different Questions

Sachs CJ. Ann Emerg Med 2018;71(2):165-7.

Physicians are experts at self-blame for poor outcomes, experiencing deep and disturbing consequences even when the care appears to be reasonable or even exceptional. Malpractice litigation makes this situation that much worse. Events preceding, during, and after a claim of medical malpractice affect the health and well-being of both patients and physicians. Surgeons with an active lawsuit in the previous 2 years are 1.64 times more likely to consider suicide in the subsequent year.1 In addition, those who consider suicide are 3.4 times more likely to report a self-perceived medical error in the previous 3 months.2 Emergency physicians, like surgeons, “exist in a culture that, like it or not, honors self-denial, prizes impervious resilience, and tends to interpret imperfection as failure.”3

In “Provider and Practice Factors Associated With Emergency Physicians Being Named in a Malpractice Claim” in this issue of Annals, Venkat et al4 searched for ways to mitigate the negative effect by attenuating malpractice claim risk. The authors sought to identify modifiable physician and practice characteristics associated with malpractice claims in a multistate emergency physician group, using 4.5 years of closed claims data. They give us 2 primary findings: first, as emergency physicians, we are likely to be sued, and second, we can’t predict or prevent it.

This editorial reviews some of the medical malpractice literature, places the work by Venkat et al in context, and suggests alternative actions to predict malpractice claims and reduce resultant provider stress. Ultimately, the work by Venkat et al suggests that future investigators should radically alter their approach to exploring, analyzing, and responding to medical malpractice.

Venkat et al remind us of the sobering fact that under the current US malpractice system, at least 75% of emergency physicians will be named in a malpractice lawsuit during their careers—and 95% if they practice until aged 65 years. The US malpractice system as a whole fails to serve the best interests of our patients, who most often do not receive satisfactory explanations or any compensation when injured, and still sabotages the patient-physician relationship.5 Malpractice allegations induce self-doubt, anger, and often depression. We may suffer for years from a form of posttraumatic stress disorder termed malpractice stress syndrome.6, 7 Lawsuits may taint our future interactions with patients and threaten our well-being at work for years and potentially for the duration of our careers.

With this as a backdrop, many authors have researched methods to avoid malpractice claims. The majority of previous research in the emergency medicine literature examines series of claims cases and in doing so cannot accurately determine the risk associated with the studied variables. One way to think about this is to consider that these previous studies were limited to variables in the numerator (cases with lawsuits) and did not incorporate the denominator (all patients treated during the time and location from which the cases arose). As a result, the variables found to be associated with malpractice risk may be just as common in cases without lawsuits as in cases with them; the case series methodology can’t determine whether a difference exists.8, 9, 10 Studies comparing physicians with multiple lawsuits (as cases) with those with only one lawsuit (as controls) lack utility in uncovering potentially predictive variables because the majority of physicians will have only one lawsuit in a 4- to 10-year database. What is found may not be generalizable because it focuses on the rare event of a physician with multiple lawsuits, who likely is not representative of most physicians facing lawsuits.11 Indeed, in the current Annals analysis, 92% of emergency physicians accrued a single lawsuit. By using both numerator data and denominator data, the research by Venkat et al improves greatly on that of previous studies exploring risk factor associations. Their approach does have the ability to differentiate provider and practice factors associated with increased risk from the larger group of all emergency department (ED) visits.

In the present study, Venkat et al explored several independent variables that the previous research suggested might be associated with malpractice risk. The variables included years in practice, board certification, admission rate (a proxy for physician risk adversity), relative value units generated hourly, total patients treated, multiple facility work, night shift work, patient experience rank (per Press Ganey), and American College of Emergency Physicians (ACEP) state malpractice grade. The authors found only 2 elements statistically associated with risk of lawsuit: increased patient volume and years in clinical practice…

The rest of the essay (subscription required):

21. Effect of ED and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients

Mathews KS, et al. Crit Care Med. 2018 Jan 30 [Epub ahead of print]

OBJECTIVES: ICU admission delays can negatively affect patient outcomes, but emergency department volume and boarding times may also affect these decisions and associated patient outcomes. We sought to investigate the effect of emergency department and ICU capacity strain on ICU admission decisions and to examine the effect of emergency department boarding time of critically ill patients on in-hospital mortality.

DESIGN: A retrospective cohort study.

SETTING: Single academic tertiary care hospital.

PATIENTS: Adult critically ill emergency department patients for whom a consult for medical ICU admission was requested, over a 21-month period.


MEASUREMENTS AND MAIN RESULTS: Patient data, including severity of illness (Mortality Probability Model III on Admission), outcomes of mortality and persistent organ dysfunction, and hourly census reports for the emergency department, for all ICUs and all adult wards were compiled. A total of 854 emergency department requests for ICU admission were logged, with 455 (53.3%) as "accept" and 399 (46.7%) as "deny" cases, with median emergency department boarding times 4.2 hours (interquartile range, 2.8-6.3 hr) and 11.7 hours (3.2-20.3 hr) and similar rates of persistent organ dysfunction and/or death 41.5% and 44.6%, respectively. Those accepted were younger (mean ± SD, 61 ± 17 vs 65 ± 18 yr) and more severely ill (median Mortality Probability Model III on Admission score, 15.3% [7.0-29.5%] vs 13.4% [6.3-25.2%]) than those denied admission. In the multivariable model, a full medical ICU was the only hospital-level factor significantly associated with a lower probability of ICU acceptance (odds ratio, 0.55 [95% CI, 0.37-0.81]). Using propensity score analysis to account for imbalances in baseline characteristics between those accepted or denied for ICU admission, longer emergency department boarding time after consult was associated with higher odds of mortality and persistent organ dysfunction (odds ratio, 1.77 [1.07-2.95]/log10 hour increase).

CONCLUSIONS: ICU admission decisions for critically ill emergency department patients are affected by medical ICU bed availability, though higher emergency department volume and other ICU occupancy did not play a role. Prolonged emergency department boarding times were associated with worse patient outcomes, suggesting a need for improved throughput and targeted care for patients awaiting ICU admission.

22. The Newest Threat to ED Procedural Sedation.

Green SM, et al. Ann Emerg Med. 2018 Feb 2 [Epub ahead of print]

Guidelines for procedural sedation first appeared in 1985—a National Institutes of Health guideline for dentists1 and an American Academy of Pediatrics guideline for children.2 Because procedural sedation is a multidisciplinary field, a wide array of specialty societies, including the American College of Emergency Physicians (ACEP), subsequently crafted and periodically update their own sedation guidelines. These documents are not mandated by regulatory bodies such as The Joint Commission or the Centers for Medicare & Medicaid Services (CMS), but are instead initiated by the specialty societies on behalf of their members. These guidelines begin with accepted core sedation principles3, 4 and include customized elements to address specialty-specific needs, challenges, and patient populations.

The American Society of Anesthesiologists (ASA) is one of the many specialty societies to issue sedation guidelines. However, ASA guidelines have been fundamentally different because they have not been crafted for their own members, but instead were unilaterally written to apply to all other sedation providers. It is inexplicable why sedation practice by anesthesiologists would be excluded from guidelines designed to ensure patient safety. Their first practice guidelines for sedation and analgesia by nonanesthesiologists were released in 1996 and updated in 2002.5, 6 The term “nonanesthesiologists” is imprecise and antiquated, given that the diversity of other specialties practicing sedation is far from homogenous and demonstrates a broad continuum of sedation skills.7, 8, 9 Rather than endorsing the ASA guidelines, major specialty societies, including ACEP and the American Academy of Pediatrics, have chosen to continue updating and applying their own established guidelines. Despite minor differences, these specialty-specific guidelines have been widely implemented with a high level of safety, and are specifically endorsed by the CMS: “A hospital could use multiple guidelines, for example, ACEP for sedation in the ED [emergency department] and ASA for anesthesia/sedation in surgical services, etc.”10

Now the ASA has released updated sedation guidelines that again assert a scope beyond the practice of anesthesiologists, stating that their guidelines “are intended for use by all providers…in any inpatient or outpatient setting.”11 These new guidelines contain vague, confusing, and misleading statements that run contrary to the existing scientific evidence and threaten the well-established sedation practices of emergency physicians and other specialists. Procedural sedation has long been a core competency in emergency medicine and critical care medicine, and our patients depend on us to provide effective sedation and analgesia for procedures that are often extremely painful (eg, cardioversion, abscess incision and drainage, fracture and dislocation reduction) or unduly frightening (eg, facial laceration repair, neuroimaging in a child). These revised ASA guidelines restrict the use of propofol and ketamine—our 2 most commonly administered sedative agents12, 13, 14, 15, 16, 17—and any adoption or enforcement of these directives would restrict emergency physician access to these drugs, resulting in widespread use of alternative agents that are less safe and provide much less effective sedation and analgesia.

Despite these concerns, there are some positive aspects to this update. First, this is the first ASA guideline to drop the patronizing and divisive7, 8, 9 “nonanesthesiologists” nomenclature.5, 6, 18, 19, 20 Second, they now concur with the ACEP recommendations in regard to fasting,13, 14, 15 stating: “In urgent or emergent situations where complete gastric emptying is not possible, do not delay moderate procedural sedation based on fasting time alone.”11 Additionally, this is the first ASA guideline to invite selected outside specialty organizations to comment during its drafting. Five of these societies have chosen to endorse these guidelines: the American Association of Oral and Maxillofacial Surgeons, the American College of Radiology, the American Dental Association, the American Society of Dentist Anesthesiologists, and the Society of Interventional Radiology. ACEP chose not to endorse the guideline when their key suggestions were not incorporated. The American College of Cardiology and the American Society for Gastrointestinal Endoscopy also declined to endorse the document. (Of note, these latter 3 societies have been omitted from the final document with their dissent unacknowledged.) Despite the disproportionate need for sedation in children, the ASA did not invite the American Academy of Pediatrics or the Society for Pediatric Sedation to provide guideline input. Similarly, no critical care specialists were included despite their common provision of sedation and their frequent management of hospital sedation services.21, 22

Most evident in this ASA guideline is a detailed itemization of now-routine sedation precautions that have been reiterated in many such guidelines from multiple specialty organizations during the past 33 years. Of concern, however, are other guideline elements that are imprecise, overly broad, or omitting important context or detail. We describe the most concerning of these as follows:
  • What Happened to Deep Sedation?...
  • An Anesthesiologist Guideline to Govern All Specialties?...
  • Propofol and Ketamine: “Medications Intended for General Anesthesia”…

In summary, the ASA guideline update contains numerous confusing statements on critical issues relating to ED sedation practice and misleading characterizations in regard to deep sedation, ketamine, and propofol that are contrary to the existing scientific evidence. Key issues such as deep sedation, guideline relationships, skill sets, and specific drugs lack sufficient clarity for meaningful understanding or consistent interpretation. Given the critical need for emergency physicians to advocate on behalf of their patients, and given that each of the vague or omitted areas favors previously asserted adverse ASA positions, we believe that emergency physicians must assume the document to be politically motivated until proven otherwise.

Emergency physicians are fully qualified by their training to administer all levels of sedation, and emergency medicine has long been at the forefront of sedation research and safe sedation practice. Non–evidence-based efforts by another specialty to dictate our scope of practice must be vigorously opposed.

22. Hemorrhagic Shock Review

Cannon JW. N Engl J Med 2018;378(4):370-379.

Understanding the pathophysiology of the body’s response to hemorrhage has led to improvements in prehospital care, more rapid hemostasis, avoidance of massive crystalloid resuscitation, and improved survival.

Full-text (subscription required):

23. Micro Bits

A. Study ties influenza to elevated heart attack risk

A study in The New England Journal of Medicine found individuals with influenza had a six times increased likelihood of having a heart attack during the first seven days of flu diagnosis. The findings, based on 364 heart attacks from mid-2008 to mid-2015 among 332 patients aged 35 or older, showed a slightly, but not statistically significant, higher heart attack risk among those older than 65 and those with influenza type B.

B. Regular dental care can reduce risk of stroke

Regular dental care was linked to a 50% reduction in the risk of stroke, compared with not seeing a dentist regularly, a study in the journal Stroke found. The risk of stroke increased with the severity of periodontal disease.

C. Increased screen time tied to lower psychological well-being in teens

Adolescents who spent more time watching TV, playing computer games, texting, and using social media and the internet had lower self-esteem, less happiness and reduced life satisfaction, compared with those who spent more time on nonscreen activities, researchers reported in the journal Emotion. The findings, based on 1991 to 2016 Monitoring the Future study data involving 1.1 million eighth-, 10th- and 12-grade students, also showed the greatest happiness among those who had less than an hour of daily screen time.

D. Walking is associated with lower mortality, even if recommended levels are not met

This cohort study examined the relationship between walking, the most common physical activity for older adults, and total mortality. Compared with inactivity, walking below minimum recommended levels is associated with lower all-cause mortality. Walking at or above physical activity recommendations is associated with further decreased risk of mortality. Walking was most strongly associated with lower risk of respiratory disease mortality followed by cardiovascular disease mortality and cancer mortality.

E. Does a Healthy Diet Protect Against Depression in Adolescence?

Oddy WH et al. Brain Behav Immun 2018 Jan 12

More-frequent consumption of healthy nutrients at age 14 was associated with fewer depressive symptoms at age 17.

Journal Watch. Daniel D. Dressler, MD, MSc, SFHM, FACP reviewing Mortensen MB and Nordestgaard BG. Ann Intern Med 2018 Jan 16.

They vary substantially in the proportions of patients who are deemed to be eligible for statin therapy.

G. People with anxiety are more likely to be bitten by dogs

Cuddling with your pet is usually a good way to unwind after a particularly challenging day. However, a new study indicates that you might want to think twice before getting too close to your dog when you’re feeling anxious as it could make them more likely to bite.

H. What Google Can do with Big Data to Predict Clinical Outcomes

Rajkomar AR, et al. Scalable and accurate deep learning for electronic health records.

Predictive modeling with electronic health record (EHR) data is anticipated to drive personalized medicine and improve healthcare quality. Constructing predictive statistical models typically requires extraction of curated predictor variables from normalized EHR data, a labor-intensive process that discards the vast majority of information in each patient's record.

We propose a representation of patients' entire, raw EHR records based on the Fast Healthcare Interoperability Resources (FHIR) format. We demonstrate that deep learning methods using this representation are capable of accurately predicting multiple medical events from multiple centers without site-specific data harmonization. We validated our approach using de-identified EHR data from two U.S. academic medical centers with 216,221 adult patients hospitalized for at least 24 hours. In the sequential format we propose, this volume of EHR data unrolled into a total of 46,864,534,945 data points, including clinical notes. Deep learning models achieved high accuracy for tasks such as predicting in-hospital mortality (AUROC across sites 0.93-0.94), 30-day unplanned readmission (AUROC 0.75-0.76), prolonged length of stay (AUROC 0.85-0.86), and all of a patient's final discharge diagnoses (frequency-weighted AUROC 0.90). These models outperformed state-of-the-art traditional predictive models in all cases. We also present a case-study of a neural-network attribution system, which illustrates how clinicians can gain some transparency into the predictions.

We believe that this approach can be used to create accurate and scalable predictions for a variety of clinical scenarios, complete with explanations that directly highlight evidence in the patient's chart.

Cornell University Library (full-text free, select pdf):

I.  Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival

Bodai BI, et al. Perm J 2018

J. Concussions Can Be Detected With New Blood Test Approved by F.D.A.

K. Opioid Analgesic Use Increases Risk for Invasive Pneumococcal Diseases: A Nested Case–Control Study

L. Study finds many ibuprofen users exceed daily dosing limit of NSAIDs

A study in Pharmacoepidemiology & Drug Safety found around 15% of adults using nonsteroidal anti-inflammatory drugs were taking the drugs at a higher daily dose than the maximum recommended dose, raising their risk for heart attacks, internal bleeding and other serious side effects. The findings, based on 1,326 ibuprofen users who completed an online daily medication diary for a week, showed 16% used ibuprofen daily, 55% took the drug at least three days a week and 37% used at least one other nonsteroidal anti-inflammatory drug during the week.

M. Differences of energy expenditure while sitting versus standing: A systematic review and meta-analysis

Results: By substituting sitting with standing for 6 hours/day, a 65 kg person will expend an additional 54 kcal/day. Assuming no increase in energy intake, this difference in energy expenditure would be translated into the energy content of about 2.5 kg of body fat mass in 1 year.

N. Aspirin use not tied to better outcomes in HF without AFib

A study in JACC: Heart Failure found patients with heart failure but without atrial fibrillation who used low-dose aspirin did not have a significantly lower risk of all-cause mortality or hospital admission for stroke or myocardial infarction. However, low-dose aspirin treatment was tied to a slightly higher risk of readmission for heart failure and to an elevated risk of myocardial infarction, according to the findings, based on nearly 12,300 individuals with new-onset heart failure enrolled in a Danish registry.

O.  Simulation Leaders Will Appreciate This

Proceedings of the 2017 AEM Consensus Conference: Catalyzing System Change Through Healthcare Simulation

Many papers—free.