Monday, April 14, 2008

Lit Bits: April 14, 2008

From the recent medical literature...

1. Federal Health Officials Launch Hospital Comparisons Web Site

March 31, 2008 — Federal health officials released the latest version of a web site Friday that lets the public compare about 2,500 hospitals on some measures of quality.

The site pulls together some information that Medicare has made available to the public since 2005. Officials say the effort would force hospitals to compete more on quality and customer services while allowing patients to shop.

"I think by this afternoon there will be hospitals looking at this site and identifying the places they need to improve," says Health and Human Services Secretary Michael O. Leavitt.

Administration officials have sought to bring more transparency to the health care marketplace. Similar Medicare sites compare nursing homes in all 50 states as well as customer satisfaction with government-sponsored private managed care plans.

The site, at, compares hospitals according to how often they meet 26 performance measures, based on Medicare data. Most are process oriented, such as how often hospital personnel give aspirin to heart attack patients, a treatment shown to cut the risk of another attack.

There's also patient satisfaction measures gleaned from surveys filled out by Medicare patients.

Two measures -- admission for heart attack or for heart failure -- give a sense of death rates for patients within 30 days of hospital admission. The site doesn't give each mortality rate. Instead it displays whether death rates at the hospital are at or below the national average.

Many hospitals and other health care providers have resisted publishing detailed outcomes data. One concern is that hospitals that routinely treat sicker patients could be penalized for poorer outcomes.

"It's still in the beginning stages, we realize that," says Elizabeth Leitz, a spokeswoman for the American Hospital Association, which leads the group that chose the site's comparison measures. "It's what we have consensus built around," Leitz says of the two health outcomes metrics on the site.

The group plans in July to introduce comparisons of average pneumonia death rates for hospitals, she says.

Leavitt acknowledges that the site does compare hospitals on many measurable health outcomes, like the success of surgery or infection rates. He likened consumer health information to the development of video games over the last 40 or so years.

"We're looking at 'Pong'," he said, referring to the rudimentary 1970s video game. "We're still learning."

But he said the effort -- while supported by hospitals and other health providers -- also contends with resistance. Leavitt says there was a "tension" between health providers who want independence and employers who need to cut rising health costs.

"There's an understandable caution, but we have an imperative we have to accomplish here," Leavitt says.

2. Report looks at reasons for adult ED visits

Source: The American Hospital Association ( Date: February 27, 2008

Pneumonia was the top reason adults were admitted to the hospital from the emergency department in 2005, according to a new report from the Agency for Healthcare Research and Quality. The report presents data on adult ED visits in 23 states from the Healthcare Cost and Utilization Project. About 19% of ED visits in those states resulted in hospital admission. Other leading reasons for admission from the ED were congestive heart failure, chest pain, heart attack and chronic obstructive pulmonary disease. The poorest communities had nearly twice the rate of ED visits as the wealthiest communities. A future report will focus on pediatric ED visits.

To view this report, please visit:

3. In Sinusitis, Signs and Symptoms Not Helpful in Decisions on Using Antibiotics

There is no reliable sign or symptom (such as facial pain or purulent discharge) to distinguish patients with sinusitis who would benefit from antibiotics, according to a Lancet report.

Researchers reanalyzed individual patient data from nine randomized trials. Some 2500 patients had been diagnosed on the basis of clinical signs and symptoms and not bacterial cultures or imaging. All were assigned to receive either an antibiotic or placebo. The researchers assessed the number of "cures" (resolution or mitigation of symptoms) as the outcome of interest.

Overall, the authors calculate an NNT of 15 to cure an additional patient with antibiotics. That number dropped to 8 among patients with purulent discharge, but the authors write "its prognostic value is not sufficient." However, they say that severe symptoms warrant prompt treatment, on the basis of patient safety.

They conclude that their results "should reassure physicians that only watchful waiting and symptomatic relief are warranted for almost all adult patients with acute rhinosinusitis-like complaints."

Lancet article (Free abstract; full text requires subscription):

4. Ketamine-Propofol Combination Sedation for Fracture Reduction in the Pediatric ED

Sharieff GQ, et al. Ped Emerg Care. 2007;23:881-884.

Objectives: To evaluate the time of onset and recovery from and the efficacy and safety of intravenous ketamine-propofol sedation for reduction of forearm fractures in the pediatric emergency department setting.

Study Design: Prospective, observational pilot study.

Methods: Children presenting to an urban pediatric emergency department requiring sedation for closed reduction of forearm fractures received ketamine 0.5 mg/kg and propofol 1 mg/kg. We measured time intervals from drug administration to reduction, recovery, and attainment of discharge criteria, and obtained ratings of depth of sedation, pain, and ease of reduction. A follow-up survey elicited patient recall, parental satisfaction, and delayed complications. Complications were recorded during the procedure and by chart review.

Results: Reduction was successful in 19 of 20 patients with one requiring open reduction. Median time intervals measured from initiation of ketamine injection were 5 minutes to reduction completion, 10 minutes to first purposeful response, and 38 minutes to suitability for discharge. Three patients recalled reduction or casting, but in no case was reduction reported to be the most painful aspect of visit. Emergency physicians and orthopedic residents rated sedation and ease of reduction favorably. Complications included mild hypoxia, vomiting, and transient ataxia. No apnea, hemodynamic compromise, dysphoria, or injection pain occurred.

Conclusions: In this pilot study, the combination of ketamine and propofol provided effective sedation with rapid recovery and no clinically significant complications for children requiring closed reduction of forearm fractures.

5. Brain Trauma Is Not the Basis for Post-Concussion Syndrome

By David Douglas. NEW YORK (Reuters Health) Mar 21 - Mild traumatic brain injury (mTBI) is often followed by acute post-concussion syndrome but does not predict the condition, according to Australian researchers.

Investigator Dr. E. Arthur Shores told Reuters Health that these results are similar to findings by other investigators who studied military personnel after combat. "Once post-traumatic stress disorder and depression was considered, the effect of mTBI was non-significant," Dr. Shores said.

He added, "Post-concussion syndrome has been a controversial diagnosis in both civilian and military populations."

In the March issue of the Journal of Neurology, Neurosurgery and Psychiatry, Dr. Shores of Macquarie University, Sydney and colleagues note that they evaluated 175 trauma patients -- 90 with mTBI and 85 without brain injury - for symptoms including poor concentration, irritability, memory problems, and mood swings. Subjects were analyzed with a modified Post-Concussion Syndrome Checklist, along with validated psychological and neuropsychological tests.

According to the report, 43.3% of mTBI patients and 43.5% of controls met the criteria for diagnosis of acute post-concussion syndrome. The strongest effect was seen in those who had had a previous affective or anxiety disorder (odds ratio 5.76). Women were at more than a 3-fold greater risk than men.

"For individuals who have mTBI," Dr. Shores, concluded, "it is important they know that symptoms they continue to experience are not due to brain injury. They can be treated with early education and psychological therapies."

In an accompanying editorial, Dr. Graham E. Powell of Powell Campbell Edelmann in London, points out the importance of taking into account the fact that some symptoms "have a high base rate of occurrence in the general population." He emphasizes that post-concussion syndrome symptoms "are rife in the general population," adding that this high base rate can lead to diagnoses which "will often be plain wrong."

J Neurol Neurosurg Psychiatry 2008;79:237,300-306.

6. Heads Up: Canadian study will derive a clinical decision rule for triage of ED patients with chest pain: “Who really can safely go home?”

Finally, Ian Stiell applies his “Ottawa Ankle Rules” methods to ED patients with chest pain!

Erik P Hess, George W Wells, Allan Jaffe and Ian G Stiell. BMC Emergency Medicine. 2008;8:3

Chest pain is the second most common chief complaint in North American Emergency Departments. Data from the U.S. suggest that 2.1% of patients with acute myocardial infarction and 2.3% of patients with unstable angina are misdiagnosed, with slightly higher rates reported in a recent Canadian study (4.6% and 6.4%, respectively). Information obtained from the history, 12-lead ECG, and a single set of cardiac enzymes is unable to identify patients who are safe for early discharge with sufficient sensitivity. The 2007 ACC/AHA guidelines for UA/NSTEMI do not identify patients at low risk for adverse cardiac events who can be safely discharged without provocative testing. As a result large numbers of low risk patients are triaged to chest pain observation units and undergo provocative testing, at significant cost to the healthcare system. Clinical decision rules use clinical findings (history, physical exam, test results) to suggest a diagnostic or therapeutic course of action. Currently no methodologically robust clinical decision rule identifies patients safe for early discharge.

The goal of this study is to derive a clinical decision rule which will allow emergency physicians to accurately identify patients with chest pain who are safe for early discharge. The study will utilize a prospective cohort design. Standardized clinical variables will be collected on all patients at least 25 years of age complaining of chest pain prior to provocative testing. Variables strongly associated with the composite outcome acute myocardial infarction, revascularization, or death will be further analyzed with multivariable analysis to derive the clinical rule. Specific aims are to: i) apply standardized clinical assessments to patients with chest pain, incorporating results of early cardiac testing; ii) determine the inter-observer reliability of the clinical information; iii) determine the statistical association between the clinical findings and the composite outcome; and iv) use multivariable analysis to derive a highly sensitive clinical decision rule to guide triage decisions.

The study will derive a highly sensitive clinical decision rule to identify low risk patients safe for early discharge. This will improve patient care, lower healthcare costs, and enhance flow in our busy and overcrowded emergency departments.

Full-text (pdf):

7. Safety and Efficacy of a Protocol Using Bougienage or Endoscopy for the Management of Coins Acutely Lodged in the Esophagus: A Large Case Series

Arms JL, et al. Ann Emerg Med. 2008;51:367-372.

Study objective
We report our experience using the bougienage procedure in the management of esophageal coins.

Observational case series of all patients presenting to our emergency departments with coins acutely lodged in the esophagus between 1994 and 2006. All patients were treated according to our protocol with either endoscopy or bougienage. Patients are eligible for bougienage if they have had a witnessed coin ingestion less than 24 hours before presentation and if esophageal coin position is confirmed by chest radiograph and there is no history of esophageal disease, surgery, or foreign body. Primary outcomes measured were complications, efficacy of procedure, hospital charges, length of stay, and return to the hospital. Length of stay and hospital charges data were gathered for patients presenting in the final 24 months of the study.

Six hundred twenty patients were identified as having esophageal coins. Three hundred fifty-five patients had a successful bougienage, and 17 patients had unsuccessful bougienage. By comparison, 248 patients underwent endoscopy, and the coin was successfully removed in all but 1 of these patients. Of patients undergoing endoscopy, 89 were eligible for bougienage, but patient, parent, or physician preference was for endoscopic management. Eleven patients required reevaluation or readmission for complaints related to esophageal coin. The only complication was subglottic edema, causing respiratory distress in a single patient who had undergone endoscopy. Patients undergoing endoscopy had an average length of stay of 6.1 hours and average hospital charges were $6,087. Patients undergoing bougienage had an average length of stay of 2.2 hours and average hospital charges of $1,884.

In properly screened patients with coins acutely lodged in the esophagus, bougienage offers a safe and effective alternative to other methods of coin management.

Accompanying Editorial

Several years ago, a previously healthy 7-year-old boy came to my emergency department (ED), having accidentally swallowed the quarter he had been carrying in his mouth while climbing a tree at school. He could “feel it right here,” he told me, pointing to his lower sternum, but was otherwise asymptomatic. A radiograph confirmed that the coin was in the distal esophagus, just above the lower esophageal sphincter. If this patient were to present to your ED today, how would you treat him?

At many, if not most, US EDs, arrangements would be made for endoscopic coin removal under general anesthesia or deep sedation, perhaps after transfer to a regional pediatric center. At other hospitals, he might undergo a removal procedure with a Foley catheter. Knowing that being older (at age 7, this boy is older than most children with esophageal coins), a boy, and having an esophageal coin lodged in the distal part of the esophagus all make spontaneous passage likelier, other clinicians might opt for “watchful waiting” for 12 to 24 hours to allow for spontaneous passage. As Arms et al describe in this issue of Annals of Emergency Medicine, bougienage is yet another option at some hospitals. Which of these is best?

Endoscopy is widely used and is the standard by which other methods are measured. As Arms et al observe, endoscopy is safe and effective but much more expensive than the other methods. Endoscopy is the method of choice for removal of many endoscopic coins, such as multiple coins, those that have been in place for a long time, or those in high-risk patients; it is also the usual backup when another method fails. The challenge has been to find a less invasive, less expensive method for low-risk situations, which are, of course, common in the pediatric population. Until recently, most such studies focused on use of a Foley catheter; the more recent literature, however, suggests that bougienage is superior to endoscopy and Foley catheter use for low-risk patients. The article by Arms et al considerably supplements that knowledge and is a valuable addition to the literature.

The spontaneous passage of acutely swallowed esophageal coins in children has also been well described. Although it seems to occur in about 30% of all comers, several factors that make spontaneous passage more likely have been described; along with those noted above, being asymptomatic also seems predictive of spontaneous passage. Watchful waiting, giving a patient several hours to pass a recently ingested, esophageal coin, has not been widely reported but seems promising. Using drugs to enhance passage is not usually successful.

So how did I treat my 7-year-old? I gave him a big drink of water. He felt the coin pass, which I confirmed with a radiograph (I now wish I had used a metal detector instead, but that is another editorial). I was taking something of a chance because giving him a drink might have delayed endoscopy, the usual method of esophageal coin removal at my institution. However, others and I had successfully used this method before. I was also aware of the following “Editor’s Note” by the then-editor of Archives of Pediatrics and Adolescent Medicine, Dr. Catherine DeAngelis: “Back in the dark ages, when I worked in a bush hospital in West Africa, we fed kids with esophageal-lodged coins gobs of the center of fresh white bread … with great success….” Much like bougienage, having a low-risk patient swallow bread, water, or something else seems to help induce passage of an esophageal coin into the stomach, converting the passive watchful waiting process into something more active, and perhaps more successful…

Conners GP. Ann Emerg Med 2008;51:373-4.

8. What is ALTE?

Jobe AH. J Pediatrics. 2008;152:365.

Apparent life threatening events (ALTE) are a major headache for both parents and emergency rooms. Infants with these events are defined as having an episode that is frightening to the observer and characterized by some combination of apnea, color change, change in muscle tone, and choking or gagging that requires vigorous stimulation. This is a rather global and imprecise definition to use diagnostically, based on caretaker history. The concern has been that ALTE is an aborted SIDS event. The consistent result of an emergency room visit for ALTE is a complex and expensive evaluation that results in no clear answer as to what caused the ALTE in most cases.

The CHIME study (Collaborative Home Infant Monitoring Evaluation) prospectively monitored term infants, siblings of SIDS, and preterm infants to learn about what kind of cardiorespiratory events were occurring. The study also enrolled 153 ALTE cases. Esani et al report that infants with ALTE differ from the well-established epidemiology of SIDS. The ALTE infants were younger, less frequently low birth weight or growth restricted, and had fewer teenage mothers. While not clearly separating the populations of ALTE and SIDS patients, the populations do have differences suggesting different etiologies. Only one infant presenting with ALTE died of SIDS. We still do not know what causes ALTE.

CHIME study:

9. Ask Young Chest Pain Patients About Cocaine Use, Guidelines Urge

Younger patients being evaluated for possible acute coronary syndrome should be asked about cocaine use, according to a scientific statement from the American Heart Association. The paper also offers diagnostic and treatment strategies for cocaine-associated chest pain.

The statement, released online in Circulation, says that while establishing cocaine use should depend primarily on self-reporting, it "may be prudent" to measure cocaine urine metabolites in patients with no or few risk factors for coronary artery disease, especially if they are young or have a history of illegal drug use.

According to the statement, there were 175,000 cocaine-related emergency room visits in 2000, and chest discomfort was a symptom in 40% of those patients.

Circulation article (Free PDF):

10. In-Home Automated Defibrillators Offer No Mortality Benefit

Putting automated external defibrillators (AEDs) in the homes of patients who've had myocardial infarctions does not lower mortality risk, according to a study published online in the New England Journal of Medicine.

Some 7000 patients with previous anterior-wall MIs who were not candidates for implantable defibrillators were randomized to have, or not have, AEDs in their homes. During roughly 3 years of follow-up, there were 450 deaths, with about one-third resulting from sudden cardiac arrest. The rate of death from any cause or sudden cardiac death did not differ significantly between the groups.

Home AEDs were used in 32 patients, of whom 14 received appropriate shocks. Only 4 survived beyond 48 hours.

The researchers note: "The very low event rate, the high proportion of unwitnessed events, and the underuse of AEDs in emergencies, rather than a lack of device efficacy, appear to explain these results."

NEJM article (Free):

NEJM editorial (Free):

11. Drug treatments for dementia are better than placebo, but not much

Ann Intern Med 2008;148:379-97; 370-78

Drug treatments for dementia include the cholinesterase inhibitors donepezil, galantamine, rivastigmine, and tacrine and the neuropeptide modifying agent memantine. A systematic review of 59 trials of reasonable quality suggests that these drugs improve cognition, but probably not enough to make a real difference to patients or carers. In general, cholinesterase inhibitors and memantine produced small but statistically significant improvements in validated cognition scores and in a score of doctors’ global impressions, relative to placebo. Results for tacrine were the least convincing. The authors found only patchy and inconsistent data on behaviour and quality of life. All the drugs had side effects.

Most of the evidence applied to people with mild or moderate Alzheimer’s disease, rather than vascular or mixed dementias. Studies were generally short term so the authors couldn’t tell whether any of the five drugs helped delay the progress of dementia. They had little discernible effect on people with only mild cognitive impairment.

An updated US guideline, based on the review, urges doctors to make treatment decisions on a case by case basis, taking into consideration patients’ and carers’ preferences, tolerability, ease of use, and cost.

12. Comparison of Octreotide and Standard Therapy Versus Standard Therapy Alone for the Treatment of Sulfonylurea-Induced Hypoglycemia

Fasano CF, et al. Ann Emerg Med. 2008;51:400-6.

Study objective
This study is designed to test the hypothesis that the administration of octreotide acetate (Sandostatin; Novartis Pharmaceuticals) in addition to standard therapy will increase serum glucose level measured at serial intervals in patients presenting to the emergency department (ED) with sulfonylurea-induced hypoglycemia compared with standard therapy alone.

This study was a prospective, double-blind, placebo-controlled trial. All adult patients who presented to the ED with hypoglycemia (serum glucose level ≤60 mg/dL) and were found to be taking a sulfonylurea or a combination of insulin and sulfonylurea were screened for participation in the study. Study participants were randomized to receive standard treatment (1 ampule of 50% dextrose intravenously and carbohydrates orally) and placebo (1 mL of 0.9% normal saline solution subcutaneously) or standard treatment plus 1 dose of octreotide 75 μg subcutaneously. Subsequent treatment interventions were at the discretion of the inpatient internal medicine service.

A total of 40 patients (18 placebo; 22 octreotide) were enrolled. The mean serum glucose measurement at presentation was placebo 35 mg/dL and octreotide 39 mg/dL. The mean glucose values for octreotide patients compared with placebo were consistently higher during the first 8 hours but showed no difference in subsequent hours. Mean glucose differences approached statistical significance from 1 to 3 hours and were significant from 4 to 8 hours after octreotide or placebo administration.

The addition of octreotide to standard therapy in hypoglycemic patients receiving treatment with a sulfonylurea increased serum glucose values for the first 8 hours after administration in our patients. Recurrent hypoglycemic episodes occurred less frequently in patients who received octreotide compared with those who received placebo.

13. People assume expensive drugs work better

JAMA 2008;299:1016-7.

People often prefer expensive branded drugs to cheaper generic alternatives, possibly because they believe expensive drugs work better. To test this hypothesis, researchers gave 82 healthy volunteers a placebo analgesic. They told half the volunteers that their pills cost $2.50 each and the other half that the pills had been discounted to just 10 cents. The volunteers thought they were testing a new fast acting opioid analgesic. They rated the pain caused by small electric shocks before and after treatment.

Volunteers given the regular priced placebo were significantly more likely to report a reduction in pain scores after treatment (85.4% v 61%, P=0.02). They also reported a significantly greater average reduction in pain scores than volunteers given the cheap placebo.

These findings suggest that when it comes to drug treatments, people equate cost with quality and quality with effectiveness, say the researchers. Which could explain why people prefer expensive cyclo-oxygenase 2 inhibitors to cheap, over-the-counter anti-inflammatory analgesics. Patients might be more willing to switch from branded to generic drugs if their doctors steered clear of loaded words such as "cheap."

14. Off-Site PCI Comparable to PCI With On-Site Backup

from Heartwire — a professional news service of WebMD. March 29, 2008 (Chicago, IL - The largest clinical analysis and comparison of PCI centers with and without surgical backup in the US has shown that off-site PCI facilities have similar outcomes to PCI centers with traditional on-site cardiac surgery. Dr Michael A Kutcher (Wake Forest University Health Sciences, Winston-Salem, NC) presented the findings from the National Cardiovascular Data Registry (NCDR) at the American College of Cardiology 57th Annual Scientific Session/i2 Summit-SCAI Annual Meeting today.

Kutcher stressed, however, that the results should not be seen as carte blanche for hospitals to go ahead and set up PCI coverage without surgical backup. "The implications of this are that off-site PCI centers can provide excellent care to patients if the program is thoughtfully developed. But we shouldn't be extrapolating from this to encourage the widespread proliferation of off-site PCI. We don't want this to be a message that every hospital should go out and develop an off-site program," he noted.

Discussant Dr Stephan Windecker (University Hospital, Bern, Switzerland) congratulated Kutcher and his team "for putting an end to a controversy that is as long as the history of angioplasty itself." The findings, said Windecker, "give impetus to update the present guidelines."

Despite limitations, off-site PCI centers perform well

Kutcher explained that the performance of PCI without backup cardiac surgery on site is controversial in the US but becoming more common. Clinical guidelines accept this practice for primary PCI in patients who are experiencing an MI but advise against it in elective PCI when the procedure is less urgent. But medical centers that offer primary PCI argue that they need to include elective PCI in the mix to survive economically and to keep staff skill levels high.

Kutcher told heartwire that there are around 300 centers in the US thought to be offering PCI without surgical backup, and only around one-third of these are participating in any kind of registry, something he believes is vital to ensure good quality control.

The NCDR is a large ongoing prospective multicenter registry "that offers a unique opportunity to provide contemporary insights into these issues," he said. For this analysis, Kutcher and colleagues assessed consecutive PCI cases reported to NCDR between January 1, 2004 and March 30, 2006 and compared 9029 patients who had PCIs performed in 61 centers without on-site cardiac surgery with 299 132 patients at 404 centers that had cardiac surgery available on site.

Off-site PCI programs had smaller bed capacities, were more likely to be in rural areas, were more likely to treat high-risk patients presenting with an MI, and had lower annual PCI volumes (70% performed fewer than the recommended 200 PCI procedures annually). Despite this, they had rates of procedural success, morbidity, emergency surgery, and risk-adjusted mortality that were comparable to on-site PCI centers.

15. Ondansetron Is as Good as Promethazine for Treating Nausea in the ED

A noninferiority trial shows that both agents are equally effective.

Ondansetron is used widely for postoperative and chemotherapy-related nausea and vomiting, but emergency department adoption has lagged somewhat, mostly because of the high cost of the drug and the effectiveness of other available agents, such as promethazine and prochlorperazine. In a randomized, double-blind, noninferiority trial, funded by the maker of ondansetron, researchers compared ondansetron with promethazine for treatment of undifferentiated nausea and vomiting in ED patients.

A convenience sample of 120 nonpregnant adults with nausea scores >40 on a validated 100-mm visual analog scale (VAS) received either promethazine (25 mg) or ondansetron (4 mg) intravenously. At 30 minutes, both groups had similar reductions in nausea scores (mean decrease, 36 mm with promethazine vs. 34 mm with ondansetron). Anxiety and sedation were measured using a self-reported nonvalidated 100-mm VAS. Promethazine and ondansetron were associated with similar reductions in anxiety scores (mean decrease, 14 mm vs. 13 mm, respectively). Sedation scores rose in both groups, but the increase was significantly greater with promethazine than with ondansetron (mean increase, 19 mm vs. 5 mm). Akathisia was reported in 3% of patients in the promethazine group only.

Comment: Ondansetron is a highly effective antiemetic agent that works as well as promethazine but with less sedation and no potential to induce akathisia, the most troubling adverse effect. Emergency physicians should consider ondansetron as a first-line, cost-effective, and clinically effective alternative to the traditional sedating anticholinergic agents.

— Diane M. Birnbaumer, MD, FACEP. Published in Journal Watch Emergency Medicine March 28, 2008. Citation: Braude D and Crandall C. Ondansetron versus promethazine to treat acute undifferentiated nausea in the emergency department: A randomized, double-blind, noninferiority trial. Acad Emerg Med 2008;15:209.

16. Responsibility for Admitted Patients

Ann Emerg Med. 2008;51:457.

The American College of Emergency Physicians (ACEP) believes that the best patient care occurs when there is no ambiguity as to which physician is responsible for each patient. Because admitted patients are sometimes held in the emergency department (ED), confusion may occur when determining which physician is responsible for an admitted patient’s care. While emergency physicians may provide care to any admitted patient during a medical emergency, emergency physicians are generally neither credentialed to provide inpatient care nor are they insured for providing inpatient care.

For these reasons, ACEP endorses the following principles:

• Regardless of the location of an admitted patient within the hospital, the ultimate responsibility for an admitted patient’s medical care rests with the admitting physician.

• Hospital policy and procedures should clearly delineate that once an admitting physician has accepted a patient, that admitting physician has assumed responsibility for the patient.

Approved by the ACEP Directors October 2007.

17. CMS Issues Updated Interpretive Guidelines on EMTALA

Date: April 03, 2007. CMS has updated its interpretive guidelines on the Emergency Medical Treatment & Labor Act (EMTALA). These guidelines are distributed to the state surveyor agencies to use during their review of potential violations. It is important for EM physicians to know what the surveyors will be looking for. The key components of the new guidance addresses the issue of on-call physician requirements; the definition of "labor"; a detailed discussion of what constitutes a medical screening examination; guidance regarding delays in service to individuals arriving via prehospital EMS (also known as the "parking" issue), and the EMTALA responsibilities of recipient hospitals with specialized capabilities or facilities. The revisions are effective immediately.

To access the full document:

18. The Importance of Increased Neck Circumference to Intubation Difficulties in Obese Patients

Gonzalez H, et al. Anesth Analg 2008; 106:1132-1136.

BACKGROUND: Using the intubation difficulty scale (IDS), we sought to confirm that obese patients are more difficult to intubate than lean patients. We assessed classical bedside tests and included neck circumference.

METHODS: We prospectively compared the incidence of difficult tracheal intubation in 70 obese [body mass index (BMI) 30 kg/m2] and 61 lean patients (BMI <30>5) or not (IDS 5), and the patient data, were compared between lean and obese patients. Preoperative measurements [BMI, neck circumference (at the level of the thyroid cartilage), width of mouth opening, sternomental distance, and thyromental distance], medical history of obstructive sleep apnea syndrome, and several scores (Mallampati, Wilson, El Ganzouri) were recorded. The view during direct laryngoscopy was graded, and the IDS was recorded. We then compared patients with IDS 5 and greater than 5, concerning each item.

RESULTS: The results indicate that difficult tracheal intubation is more frequent in obese than in lean patients (14.3% vs 3%; P = 0.03). In the patients with IDS greater than 5, thyromental distance, BMI, large neck circumference, and higher Mallampati score were the only predictors of potential intubation problems.

CONCLUSION: We found that problematic intubation was associated with thyromental distance, increasing neck circumference, BMI, and a Mallampati score of 3. Neck circumference should be assessed preoperatively to predict difficult intubation.

19. Just 20 Minutes of Physical Activity per Week Improves Mental Health

Being physically active just once a week for 20 minutes is enough to boost mental health, according to a cross-sectional study in the British Journal of Sports Medicine.

Researchers surveyed nearly 20,000 Scottish adults to determine their level of psychological distress and self-reported frequency of physical activity, including sports, walking, and domestic activity (e.g., heavy housework and gardening).

In adjusted analyses, at least one 20-minute session a week of any type of activity was associated with lower risk for psychological distress. For sports and all activity types combined, risk reductions increased as the frequency of activity increased.

British Journal of Sports Medicine abstract:

20. ACS Patients Do Better in Clinical-Trial Hospitals

from Heartwire — a professional news service of WebMD. March 26, 2008 (Edmonton, AB, Canada) – Hospitals that participate in clinical trials appear to provide better care for ACS patients than hospitals that do not participate in clinical trials, according to a new study.

The study, published in the March 24, 2008 issue of the Archives of Internal Medicine, was conducted by a team led by Dr Sumit Majumdar (University of Alberta, Edmonton).

They explain that the quality of care for conditions such as acute coronary syndromes has improved over recent years in response to new evidence from clinical trials but that the rate of improvement has been slow and there has been marked variability between hospitals.

Noting that clinical trials demand that trial subjects receive safe, high-quality, protocol-driven care, they suggest the same elements required for hospitals to participate in clinical trials could induce beneficial changes in the hospital environment, thereby leading to better processes and outcomes of care for patients treated outside the trial setting.

To test this hypothesis, they studied 174 062 NSTEMI ACS patients treated at 494 hospitals that were part of the CRUSADE registry. Hospitals were classified into tertiles by percentage of patients concurrently enrolled in NSTEMI ACS trials. In total, 4590 patients (2.6%) were enrolled in clinical trials, with 145 hospitals having no enrollment, 226 hospitals having low enrollment (a midpoint of 1% enrollment) and 123 hospitals having high enrollment (a midpoint of 4.9% enrollment).

Results showed that adherence to clinical guidelines increased and in-hospital mortality decreased with increasing tertiles of trial participation.

21. Antibiotic use results in resistance even for individual children

Del Mar C. BMJ 2007;335:407-408

In a recent issue of BMJ, Chung and colleagues (BMJ 2007;335:429) report that community prescribing of a beta-lactam antibiotic for acute respiratory infection doubled the prevalence of antibiotic resistant bacteria in individual children. This antibiotic resistance was transferred as a gene encoding beta-lactamase from other species of bacteria to Haemophilus. What do these results mean for the future of antibiotic prescribing in general practice?

Antibiotic resistance will probably eventually appear by natural selection for every new antibiotic developed by the drug industry, and the race to produce new drugs ahead of resistance is run ever closer. Antibiotics should be thought of like oil, a non-renewable resource to be carefully husbanded. What we use now cannot be used some time in the future.

The problem is that there is no scientific solution to convincing people not to seize for their own benefit a common resource best nurtured for the good of the community. It is especially difficult for doctors treating a sick child not to provide (or, at least seem to provide) the best care, covering all possible outcomes, whatever the potential consequences for antibiotic resistance. What tools could clinicians have to balance the needs of the patient against protecting community resources?

It seemed for a while that draconian rationing would be needed to curb doctors' freedom to prescribe antibiotics—special administrative barriers to obstruct their use, rules of indications settled centrally, and so on. There are three reasons why this has not been necessary.

Firstly, one of the consequences of evidence based practice is the finding that antibiotics are minimally effective against most common childhood infections, mainly acute respiratory infections. This applies not only to infections commonly caused by viruses (colds and coughs), but even those usually caused by bacteria (especially sore throats, and acute otitis media). This message has been slow to infiltrate the community, although it is now appreciated by more people, and doctors now prescribe antibiotics less frequently—especially for sore throats and colds, if not for acute otitis media and bronchitis.

Secondly, in some countries doctors delay the access to antibiotics as a type of educational ploy. A prescription is written (to show willing), but either left to be picked up later, or given to the parents to be filled at the pharmacy only if the child does not recover. This is effective at reducing antibiotic use. However, there is a problem. It is slightly dishonest, implying that starting antibiotics later is no less effective than using them immediately, which in at least some cases is not true. In a perfect world we would educate patients in a less indirect, if more difficult and longer, way.

The third reason comes from the personalisation of resistance from a population perspective (remote and indirect) to the individual (immediate and direct). The theoretical possibility that uncontrolled antibiotic use would increase resistance was confirmed by empirical studies. Australian children prescribed antibiotics in the previous two months were twice as likely to have beta-lactam penicillin resistant respiratory streptococci than children who were not prescribed these drugs, an effect that had not worn off six months later. The study by Chung and colleagues helps us better understand the mechanisms—how resistance is transferred between species in the child.

Why does this matter? These data will be seized on by those trying to curb antibiotic prescribing to provide a more cogent argument for not using antibiotics. The argument now focuses on the risks of antibiotic resistance to the individual patient—carrying bacteria with those genes might confer a greater risk of resistance if they later have a severe infection that needs antibiotic rescue. This possibility opens an agenda for future research. Can we test whether people with a serious infection died because of a prescription of antibiotics for a more trivial infection in the recent past?

Another potential research question might come from trying different approaches entirely, thinking about that vast horde of bacteria we carry around with us. To what extent is infection the consequence of an imbalance of this population, rather than our current oversimplified model of a pathogenic bacterium entering the body? We can offset diarrhoea caused by antibiotics by populating the gastrointestinal tract with "friendly" commensal lactobacilli. Some preliminary research has shown the same can work for acute otitis media.

In the meantime, doctors have new information to help convince patients (and themselves) that prescribing antibiotics for minor upper respiratory infections should be reserved for occasions when we really need them.