Thursday, August 28, 2008

Lit Bits: August 28, 2008

From the recent medical literature...

1. Emergency Department Visits Up Sharply From 1996 to 2006, CDC Says

Date: August 07, 2008. The number of ED visits in the U.S. increased by 36% to 119 million in 2006 from 90 million in 1996, according to a CDC report on hospital use released on Wednesday, the AP/Miami Herald reports. At the same time, the number of EDs nationwide declined from about 4,000 to about 3,800, contributing to an increase in ED treatment wait times.

The findings are based on a national survey of 362 hospital EDs.

According to the report, average ED wait time increased to about 56 minutes in 2006, compared with 38 minutes in 1997. However, the increasing ED wait time is misleading because urban EDs with waits longer than an hour boost the average, according to Catharine Burt of the National Center for Health Statistics at CDC. The report's lead author, Stephen Pitts of CDC, said that half of ED users had wait times of 31 minutes or less.

Billy Mallon, president of the California chapter of the American College of Emergency Physicians, said that California has the lowest percentage of EDs per capita, at 6.12 per one million residents.

ED Overcrowding

Several factors contribute to overcrowding in the nation's EDs. Pitts said that it is getting more difficult for U.S. residents to schedule primary care appointments, which contributes to the rise in ED use. He said this trend applies to Medicare and Medicaid beneficiaries in particular.

The report found that 82 of every 100 Medicaid beneficiaries used ED care in 2006, compared to 21 of every 100 people with private insurance.

Pitts said a limited number of inpatient beds also is contributing to ED overcrowding as patients wait in the ED to be admitted. As hospitals have reduced bed capacity, the "major solution over the past 10 years has been to allow these patients to sit in the hallways in the ER," Pitts said.

More than half of hospital admissions in 2006 were through EDs, a 38% increase since 1996, the report found.

According to the report, although the number of uninsured U.S. residents increased by more than 5 million since 1996 to about 47 million, the growing uninsured population did not account for higher ED use.

The report also found that the overall growth in population did not account for the trend. According to the report, about 40% of ED patients had private insurance; about 25% received health coverage through state programs for children; about 17% were Medicare beneficiaries; and about 17% were uninsured.

Other ED findings

The report also found that:

- ED use overall increased by 18%;
-About 13% of ED visits led to a hospital admission;
-Infants had the highest use of EDs of any age group;
-People older than 75 were the second-highest users of ED care; and
-ED or hospital outpatient department visits accounted for 38% of care used by blacks, compared with 17% for whites.

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2. Silver-Coated Endotracheal Tube Reduces Risk for Ventilator-Associated Pneumonia

Laurie Barclay, MD. August 19, 2008 — Use of a silver-coated endotracheal tube significantly reduces the incidence of microbiologically confirmed ventilator-associated pneumonia (VAP), according to the results of a large, randomized, multicenter study reported in the August 20 issue of the Journal of the American Medical Association.

"VAP causes substantial morbidity," write Marin H. Kollef, MD, from the Washington University School of Medicine in St. Louis, Missouri, and colleagues from the North American Silver-Coated Endotracheal Tube Investigation Group. "A silver-coated endotracheal tube has been designed to reduce VAP incidence by preventing bacterial colonization and biofilm formation."

The goal of this prospective, single-blind study conducted in 54 centers in North America was to evaluate whether use of a silver-coated endotracheal tube would reduce the incidence of microbiologically confirmed VAP.

Of 9417 adult patients aged 18 years or older who were screened between 2002 and 2006, a total of 2003 patients who were expected to need mechanical ventilation for at least 24 hours were randomly assigned to undergo intubation with 1 of 2 high-volume, low-pressure endotracheal tubes. These tubes were similar except that the experimental tube had a silver coating.

The main endpoint was incidence of VAP, diagnosed from quantitative bronchoalveolar lavage fluid culture with at least 104 colony-forming units/mL in patients intubated for at least 24 hours. Secondary endpoints were VAP incidence in all intubated patients, time to VAP onset, length of intubation and duration of intensive care unit and hospital stay, mortality rates, and adverse events.

Rates of microbiologically confirmed VAP in patients intubated for at least 24 hours were 4.8% (37/766 patients; 95% confidence interval [CI], 3.4% - 6.6%) in the group receiving the silver-coated tube and 7.5% (56/743; 95% CI, 5.7% - 9.7%; P = .03) in the group receiving the uncoated tube (relative risk reduction, 35.9%; 95% CI, 3.6% - 69.0%).

Rates of microbiologically confirmed VAP in all intubated patients were 3.8% (37/968; 95% CI, 2.7% - 5.2%) in the experimental group and 5.8% (56/964; 95% CI, 4.4% - 7.5%; P = .04) in the control group (relative risk reduction, 34.2%; 95% CI, 1.2% - 67.9%).

Use of the silver-coated endotracheal tube was associated with delayed occurrence of VAP (P = .005), but there were no statistically significant between-group differences in durations of intubation, intensive care unit stay, and hospital stay. Mortality rates and frequency and severity of adverse events were also similar in both groups.

"Patients receiving a silver-coated endotracheal tube had a statistically significant reduction in the incidence of VAP and delayed time to VAP occurrence compared with those receiving a similar, uncoated tube," the study authors write. "The silver-coated endotracheal tube appears to offer a unique approach because it is the first intervention that becomes user-independent after intubation, requiring no further action by the clinician."

Limitations of this study include single blinding rather than double blinding; use of a small, fixed block size stratified by center; other factors possibly contributing to between-group differences in VAP rates; study protocol not standardizing prevention strategies; and a protective effect of higher severity-of-illness scores against development of VAP.

In an accompanying editorial, Jean Chastre, MD, from Institut de Cardiologie, Groupe Hospitalier Pitié-Salpê trière in Paris, France, discusses the study limitations.

"Important uncertainties exist regarding the exact benefit of silver-coated endotracheal tubes," Dr. Chastre writes. "Consequently, silver coated tubes should not be viewed as the definitive answer for VAP prevention, and, until additional data confirm the clinical effectiveness and cost benefit of these devices, their use should be restricted to high-risk patients treated in ICUs [intensive care units] with benchmark value-based infection rates that remain above institutional goals despite implementation of a comprehensive strategy of usual preventive measures to prevent VAP."

CR Bard Inc supported this study and provided grant support to all of the study authors. Some of the study authors have disclosed various financial relationships with Kimberly Clark, Elan, Merck, Pfizer, Bayer, GlaxoSmithKline, Boehringer Ingelheim, KCI, sanofi-aventis, Johnson & Johnson, Easi, Hospira, Nomir Medical Technologies, Arpida, Cubist, Elan, Ortho-McNeil, Sanofi Pasteur, Wyeth, Bayer-Nektar, Nestle Clinical Nutrition, Lilly, Corbett Accel Healthcare, National Institutes of Health, Novartis, and/or Maquet. Dr. Chastre has received consulting and lecture fees from Pfizer, Brahms, Wyeth, Johnson & Johnson, Bayer-Nektar, and Arpida.

JAMA. 2008.300:805-813, 842-844.

3. Triage Pain Scores and the Desire for and Use of Analgesics

Singer AJ, et al. Ann Emerg Med. 2008; in press.

Study objective
Inadequate analgesia (oligoanalgesia) is a common phenomenon. In an effort to improve pain recognition and management, pain scores are mandated by The Joint Commission. When patients with pain do not receive analgesics, treatment is considered deficient. However, the mere presence of pain does not imply that all patients desire analgesics. We determine how often patients in pain desire and receive analgesics in the emergency department (ED). We hypothesize that many ED patients in pain do not desire analgesics and that most who want them receive them.

We conducted a prospective observational study of pain-related visits to an academic ED during the spring of 2007. Standardized collection of demographic and clinical data was performed, and patients rated their pain severity on a 0 to 10 numeric rating scale. The main outcome measures were the desire for and administration of analgesics during the ED visit. Univariate and multivariate logistic regression was used to identify factors associated with patient desire for and administration of analgesics.

We enrolled 392 patients. Mean (SD) age was 39 years (19), 50% were female patients, 76% were white. Mean (SD) initial pain score was 7.1 (2). Of the 392 patients, 199 (51% [95% confidence interval (CI) 46% to 56%]) desired analgesics and 227 (58% [95% CI 53% to 63%]) received analgesics within 92 (SD 106) minutes. Of patients desiring analgesics, 162 (81% [95% CI 75% to 86%]) received them. Reasons for not wanting analgesics included pain tolerable (47%), analgesic taken at home (11%), and wanting to remain alert (7%). Pain scores were higher in those patients who wanted analgesics than in those patients who did not want analgesics (7.8 [95% CI 7.5 to 8.1] versus 6.4 [95% CI 6.1 to 6.7]; difference 1.4 [95% CI 0.9 to 1.8]). In multivariate analysis, pain scores (odds ratio [OR] 1.3 for every 1-point increase in pain score) and constant pain (OR 2.0) were significant factors that predicted wanting analgesics, whereas pain scores (OR 1.2) and desiring analgesics (OR 7.4) were significant predictors of receiving analgesics.

Nearly half of all ED patients in pain do not desire analgesics and most who desire analgesics receive them. Although the average pain score for patients not wanting analgesics was lower, it was often in the moderate to severe range. Patients should be asked whether they have pain and whether they want analgesics regardless of their pain scores.

4. Coronary Multidetector CT Cost-Effective for Triage of Acute Chest Pain Patients

NEW YORK (Reuters Health) Aug 18 - Compared with standard protocols for assessing acute chest pain in emergency department patients, the use of coronary multidetector CT (MDCT) is modestly more effective and offers cost savings in the case of women, according to a report in the August issue of the American Journal of Roentgenology.

"Coronary CT angiography may be a useful adjunct to care in the emergency department setting when patients present with acute chest pain," Dr. Joseph A. Ladapo with the Harvard Ph.D. Program in Health Policy, Cambridge, Massachusetts told Reuters Health. "I think this finding provides support for people who feel like this technology needs be studied further."

Dr. Ladapo and colleagues used a Monte Carlo microsimulation model to compare the standard of care with MDCT coronary angiography-based management in the triage of patients with low-risk chest pain who present to the emergency department.

For a 55 year-old man, coronary MDCT increased emergency department and hospital costs by $110 and raised total health care expenditures by $200, the authors report, but for a similarly aged woman, it decreased emergency department and hospital costs by $410 and decreased total health care expenditures by $380.

Small incremental improvements in unadjusted and quality-adjusted life expectancy were seen with coronary MDCT in both sexes, the report indicates.

The incremental cost-effectiveness of coronary MDCT management (compared with standard of care) was $6400 per quality-adjusted life-year in men, the researchers note. The strategy was cost-saving in women.

Most patients who were wrongfully discharged from the emergency department after being triaged with MDCT angiography faced a low risk of mortality from the missed diagnosis, the investigators say.

"Our results suggest that 64-MDCT coronary angiography may be a safe addition to the management of low-risk patients with acute chest pain and is likely to be cost-saving in women and marginally more expensive than the standard of care in men," the authors conclude.

"Because coronary CT angiography is so good at ruling out disease, women -- along with other patients with a low likelihood of disease -- are much more likely to avoid a costly admission," Dr. Ladapo explained. "I think there's a strong case for reimbursing this technology when it's used in women, but it's cost-effective and ought to be reimbursed in men, too."

He added, "I don't think emergency departments need to rush to start using the exam on their acute chest pain patients, but I do think that it's worth supporting clinical trials of its application."

Am J Roentgenol 2008;191:455-463.

5. AHA Publishes Statement on Integrating Prehospital ECGs Into Care for ACS Patients

A Scientific Statement From the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology

Michael O'Riordan. From Heartwire — a professional news service of WebMD

August 14, 2008 — The American Heart Association (AHA) has issued a scientific statement on the use of prehospital electrocardiograms (ECGs) to improve the quality of care delivered to patients with ST-segment-elevation MI (STEMI), published online August 13, 2008 in Circulation. The central challenge, say the authors, will not be in acquiring the ECG, but rather in using and integrating the diagnostic information obtained by emergency medical service (EMS) personnel into existing systems of care.

"First medical contact with a patient is usually with the EMS, and this is the next phase of coordination that we need to reach out to," said lead author Dr Henry Ting (Mayo Clinic, Rochester, MN). "We've coordinated the emergency department, the cath lab, and the cardiology group and have done well with reducing door-to-balloon times, but we've not truly engaged the prehospital phase of care. This is critically important."

The AHA national guidelines, as well as other consensus and scientific statements, recommend the acquisition and use of prehospital ECGs by EMS for the evaluation of patients with suspected acute coronary syndrome. The current recommendation is class 2a with a B level of evidence. Speaking with heartwire, Ting said that the technology is currently available, but that hospitals do not have protocols in place that allow prehospital ECGs to serve any useful purpose.

"For the past 10 years, this equipment has been available to many paramedics, but what is happening is that when they acquire the ECG it's not really utilized," said Ting. "It's acquired, then the patient is brought to the emergency department, and in hospitals without these systems of care, they're told this is a patient with chest pain, and we have an ECG, but then the patient is placed in a critical-care room and receives another ECG. Where's the value in that?"

Not a one-size-fits-all solution

In the scientific statement, the authors review the benefits of using prehospital ECGs and the barriers and challenges to routine use and recommend approaches for using the diagnostic information for improving quality of care. In terms of benefits, Ting said the Mayo Clinic has been incorporating the use of prehospital ECGs for one year, and in doing so, has reduced door-to-balloon times to consistently less than 30 minutes, with 25 minutes being the average.

Ting said there are many ways of interpreting the ECG once it has been obtained. Computer algorithms, paramedic interpretation, and wirelessly transmitting the data to a physician for interpretation are three ways to interpret the data. The diversity of the EMS providers and the differing sizes of cities they cover, as well as wireless coverage available to transmit data, are not likely to lead to a one-size-fits-all solution, he said.

A recent survey found that 90% of EMS systems serving the largest US cities have 12-lead ECG equipment, and there are prehospital ECG programs in Boston, Los Angeles County, and North Carolina, as well as in Ottawa, ON. Paramedics in Boston, for example, are allowed to bypass non–percutaneous coronary intervention (PCI) hospitals and have an emergency-department physician activate the cardiac cath lab. North Carolina, on the other hand, allows paramedics to occasionally divert some STEMI patients to PCI hospitals and activate the cath lab directly (or have it activated by an emergency-department physician). Paramedics in Ottawa can also activate the cath lab directly through a central operator. Los Angeles County paramedics use a computer algorithm to interpret the ECG, and the cath lab is activated by the emergency department based on this diagnosis.

Allowing paramedics to "do something downstream" with the information is critical, said Ting, as is changing when the paramedics perform the ECG. "If you truly want to coordinate things, you want to start the prehospital ECG as early as possible in the examination," he said. "Once you establish that the patient has stable vital signs and doesn't have a cardiac arrhythmia, you probably want to do a prehospital ECG at the scene, as early as possible. If you detect ST elevation, the next steps are very different from treating a patient who has chest pain but no ST elevation."

Implementing prehospital ECGs into existing systems of care has the potential to "change the ball game," said Ting. He noted that the focus should begin to move away from door-to-balloon times toward a measure that provides a gauge of quality and performance that is more patient centered. The national "Door to Balloon: An Alliance for Quality" campaign launched in 2006 has helped improve the timeliness of lifesaving therapy for myocardial infarction (MI) patients at all US hospitals that perform emergency angioplasty, but from a patient perspective, first medical contact to balloon is a more relevant measure of quality of care.

Ting added that too many patients still take themselves to the emergency department or are driven there by friends or family, a decision that affects the course of care because it's impossible to obtain a prehospital ECG and then activate all the necessary hospital teams.

"The public doesn't perceive EMS as transforming care," said Ting. "They view it as transportation with sirens. They think, 'If Uncle Joe can drive me there just as fast, then why do I need to call 911 and create all the hassle in the neighborhood?' But the prehospital ECG can really change the course of treatment, something that can't happen when you drive yourself or have a friend take you."

Dr. Ting has received research grants from the American College of Cardiology and the Mayo Foundation for Medical Education and Research. A complete list of disclosures is available in the original article.

Source: Ting HH, Krumholz HM, Bradley EH et al. Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome. Circulation. 2008;

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6. When Is it Appropriate to Use Methotrexate for Ectopic Pregnancy in the Emergency Department?

Noelle A. Rotondo, DO, Associate Professor, Penn State Hershey Medical Center, Hershey, Pennsylvania; Staff Physician, York Hospital, York, Pennsylvania

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7. I Won’t Believe You, but Tell Me the Prognosis Anyway

Physicians’ prognoses are desired and discounted at the same time.

Zier LS, et al. Critical Care Medicine. 2008;36:2341-2347.

Objectives: Although discussing a prognosis is a duty of physicians caring for critically ill patients, little is known about surrogate decision-makers' beliefs about physicians' ability to prognosticate. We sought to determine: 1) surrogates' beliefs about whether physicians can accurately prognosticate for critically ill patients; and 2) how individuals use prognostic information in their role as surrogate decision-makers.

Design, Setting, and Patients: Multicenter study in intensive care units of a public hospital, a tertiary care hospital, and a veterans' hospital. We conducted semistructured interviews with 50 surrogate decision-makers of critically ill patients. We analyzed the interview transcripts using grounded theory methods to inductively develop a framework to describe surrogates' beliefs about physicians' ability to prognosticate. Validation methods included triangulation by multidisciplinary analysis and member checking.

Measurements and Main Results: Overall, 88% (44 of 50) of surrogates expressed doubt about physicians' ability to prognosticate for critically ill patients. Four distinct themes emerged that explained surrogates' doubts about prognostic accuracy: a belief that God could alter the course of the illness, a belief that predicting the future is inherently uncertain, prior experiences where physicians' prognostications were inaccurate, and experiences with prognostication during the patient's intensive care unit stay. Participants also identified several factors that led to belief in physicians' prognostications, such as receiving similar prognostic estimates from multiple physicians and prior experiences with accurate prognostication. Surrogates' doubts about prognostic accuracy did not prevent them from wanting prognostic information. Instead, most surrogate decision-makers view physicians' prognostications as rough estimates that are valuable in informing decisions, but are not determinative. Surrogates identified the act of prognostic disclosure as a key step in preparing emotionally and practically for the possibility that a patient may not survive.

Conclusions: Although many surrogate decision-makers harbor some doubt about the accuracy of physicians' prognostications, they highly value discussions about prognosis and use the information for multiple purposes.

8. Furosemide for Emergency Management of Hypercalcemia: An Unproven yet Common Practice

LeGrand SB, et al. Ann Intern Med. 2008;149:259-263.

Although primary hyperparathyroidism is the most common cause of hypercalcemia, cancer is the most common cause requiring inpatient intervention. An estimated 10% to 20% of all patients with cancer have hypercalcemia at some point in their disease trajectory, particularly in advanced disease. Aggressive saline hydration and varying doses of furosemide continue to be the standard of care for emergency management.

However, a review of the evidence for the use of furosemide in the medical management of hypercalcemia yields only case reports published before the introduction of bisphosphonates, in contrast to multiple randomized, controlled trials supporting the use of bisphosphonates. The use of furosemide in the management of hypercalcemia should no longer be recommended.

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9. ED Patients Often Don't Understand Discharge Instructions

NEW YORK (Reuters Health) Jul 22 - Patients often fail to fully comprehend the treatment they receive during an emergency department visit or recall instructions for their care after they leave, new research suggests.

More often than not, these patients aren't even aware that they have not understood what transpired or remembered what they were told, the investigators note in the Annals of Emergency Medicine, published online July 7.

To shed light on the communication process that occurs in this setting, Dr. Kirsten G. Engel at Northwestern University in Chicago and colleagues interviewed 140 adult English-speaking patients or their primary caregivers after discharge from emergency departments at two teaching hospitals. Subjects were asked questions about four domains: their diagnosis and the cause of their symptoms, the care they received, discharge recommendations, and return instructions.

Results showed that 78% of patients or their caregivers demonstrated deficient comprehension in at least one domain, and 51% had deficits in two or more domains.

At 34%, the highest rate of mistakes involved after-care, "raising significant concerns about patients' ability to adhere to discharge instructions and recommendations after leaving the ED," the investigators note.

"Moreover," they add, "our study suggests that we cannot simply ask patients to identify their comprehension deficiencies because the majority did not report difficulties in areas in which deficits were objectively demonstrated."

Specifically, subjects were unaware of their comprehension deficits 80% of the time.

Dr. Engel's group recommends that clinicians test patients' understanding by asking them to repeat information in their own words. Improving content and organization of written discharge instructions may also be of benefit.

Engel KG, et al.Ann Emerg Med 2008. In press

10. Telemedicine for Stroke Patients

Telemedicine consultation with a stroke-certified neurologist might increase appropriate use of thrombolytic agents in stroke patients.

Many patients with ischemic stroke who are eligible for alteplase therapy do not receive it because the agent must be administered within 3 hours from onset of symptoms and because emergency physicians might want to involve stroke neurologists in primary decision making regarding the use of thrombolytics. Researchers evaluated whether remote consultation with a stroke neurologist could increase appropriate use of thrombolytic agents for stroke patients.

Patients with acute stroke symptoms who presented to one of four remote hospitals from 2004 to 2007 were randomized to telemedicine or telephone-only consultation by neurologists who were National Institute of Health Stroke Scale (NIHSS) certified. During the telemedicine consultation, the consultant took a medical history, performed a physical assessment, calculated the NIHSS score, and reviewed head computed tomography (CT) scans, in concert with the local EP. Telephone consultations differed in that the consultant could not speak directly with or view the patient and relied on the local radiologist’s interpretation of the CT scan. In both scenarios, the consultant made a decision about whether to administer thrombolytic agents. The correctness of the decision — the primary outcome measure — was determined by an independent committee of stroke specialists.

Of 222 patients, 104 in the telemedicine group and 103 in the telephone group completed the study. Mean NIHSS scores at presentation were significantly higher in the telemedicine group than in the telephone group (11.4 vs. 7.7). Correct decision making was significantly more likely in the telemedicine group than in the telephone group (98% vs. 82%; odds ratio, 10.9). However, no differences were noted between groups in any of the secondary outcome variables, including rate of alteplase administration (28% vs. 23%), 90-day functional outcomes, mortality, or rate of intracranial hemorrhage after alteplase administration (7% vs. 8%). The time from call to decision making was significantly longer in the telemedicine group than in the telephone group (65 vs. 55 minutes).

Comment: This study suggests that remote consultation with a stroke neurologist can obviate the need for an on-site neurologist and enable high and appropriate rates of thrombolytic administration for patients with ischemic stroke. Telemedicine, which is expensive and not routinely available, provided better decision making but no other derivative advantages.

— John A. Marx, MD, FAAEM, FACEP. Published in Journal Watch EM August 22, 2008.
Citation: Meyer BC et al. Lancet Neurol 2008 Sep; 7:787.

11. Staphylococcus aureus Community-Acquired Pneumonia During the 2006 to 2007 Influenza Season

Kallen AJ, et al. Ann Emerg Med. 2008; in press.

Study objective
Staphylococcus aureus is a cause of community-acquired pneumonia that can follow influenza infection. In response to a number of cases reported to public health authorities in early 2007, additional case reports were solicited nationwide to better define S aureus community-acquired pneumonia during the 2006 to 2007 influenza season.

Cases were defined as primary community-acquired pneumonia caused by S aureus occurring between November 1, 2006, and April 30, 2007. Case finding was conducted through an Emerging Infections Network survey and through contacts with state and local health departments.

Overall, 51 cases were reported from 19 states; 37 (79%) of 47 with known susceptibilities involved infection with methicillin-resistant S aureus (MRSA). The median age of case patients was 16 years, and 44% had no known pertinent medical history. Twenty-two (47%) of 47 case patients with information about other illnesses were diagnosed with a concurrent or antecedent viral infection during their illness, and 11 of 33 (33%) who were tested had laboratory-confirmed influenza. Of the 37 patients with MRSA infection, 16 (43%) were empirically treated with antimicrobial agents recommended for MRSA community-acquired pneumonia. Twenty-four (51%) of 47 patients for whom final disposition was known died a median of 4 days after symptom onset.

S aureus continues to cause community-acquired pneumonia, with most reported cases caused by MRSA and many occurring with or after influenza. In this series, patients were often otherwise healthy young people and mortality rates were high. Further prospective investigation is warranted to clarify infection incidence, risk factors, and preventive measures.

12. In-Hospital Bed-to-Nurse Ratio Linked with Survival to Discharge After Out-of-Hospital Cardiac Arrest

Patients admitted to hospitals with a bed-to-nurse ratio less than 1 were 1.5 times more likely to survive to hospital discharge than those admitted to hospitals with higher ratios.

Background. Previous literature has identified patient and emergency medical services (EMS) system factors that are associated with survival of out-of-hospital cardiac arrest patients.

Objective. To determine variability in rates of survival to discharge of resuscitated adult out-of-hospital cardiac arrest patients and to identify hospital-related factors associated with survival.

Methods. This was a retrospective, observational study of all adult (21 years or older) out-of-hospital Utstein criteria cardiac-etiology arrests treated by Milwaukee County EMS during the period 1995-2005 and surviving to hospital intensive care unit admission. The primary outcome measure was survival to hospital discharge. Logistic regression analysis was used to compare the odds of survival between hospitals, patient factors, and hospital factors.

Results. 1,702 patients at eight receiving hospitals were included in the study analyses. Hospital survival rates ranged from 29% to 42%. Patient and case factors associated with increased survival included younger age, male gender, nonwhite race, witnessed arrest in a public location, bystander cardiopulmonary resuscitation (CPR), a modest number of defibrillations, and initial cardiac rhythm of ventricular tachycardia. The only hospital characteristic correlated with survival was the number of beds per nurse. Patients admitted to a hospital with a ratio of beds to nurse less than 1.0 were over 1.5 times more likely to survive.

Conclusions. Survival to discharge of resuscitated adult out-of-hospital cardiac arrest patients may vary by receiving hospital. A hospital's ratio of beds to nurse and several patient/case f actors are correlated with survival. Further research is warranted to investigate how this may affect resuscitation care, EMS transport policy, and research design.

Lui JM, et al. Prehospital Emerg Care. 2008;12:339–346.

13. Out-of-Hospital Continuous Positive Airway Pressure Ventilation Versus Usual Care in Acute Respiratory Failure: A Randomized Controlled Trial

Thompson J. Ann Emerg Med. 2008;52:232-241.e1

Study objective
Continuous positive airway pressure ventilation (CPAP) in appropriately selected patients with acute respiratory failure has been shown to reduce the need for tracheal intubation in hospital. Despite several case series, the effectiveness of out-of-hospital CPAP has not been rigorously studied. We performed a prospective, randomized, nonblinded, controlled trial to determine whether patients in severe respiratory distress treated with CPAP in the out-of-hospital setting have lower overall tracheal intubation rates than those treated with usual care.

Out-of-hospital patients in severe respiratory distress, with failing respiratory efforts, were eligible for the study. The study was approved under exception to informed consent guidelines. Patients were randomized to receive either usual care, including conventional medications plus oxygen by facemask, bag-valve-mask ventilation, or tracheal intubation, or conventional medications plus out-of-hospital CPAP. The primary outcome was need for tracheal intubation during the out-of-hospital/hospital episode of care. Mortality and length of stay were secondary outcomes of interest.

In total, 71 patients were enrolled into the study, with 1 patient in each group lost to follow-up after refusing full consent. There were no important differences in baseline physiologic parameters, out-of-hospital scene times, or emergency department diagnosis between groups. In the usual care group, 17 of 34 (50%) patients were intubated versus 7 of 35 (20%) in the CPAP group (unadjusted odds ratio [OR] 0.25; 95% confidence interval [CI] 0.09 to 0.73; adjusted OR 0.16; 95% CI 0.04 to 0.7; number needed to treat 3; 95% CI 2 to 12). Mortality was 12 of 34 (35.3%) in the usual care versus 5 of 35 (14.3%) in the CPAP group (unadjusted OR 0.3; 95% CI 0.09 to 0.99).

Paramedics can be trained to use CPAP for patients in severe respiratory failure. There was an absolute reduction in tracheal intubation rate of 30% and an absolute reduction in mortality of 21% in appropriately selected out-of-hospital patients who received CPAP instead of usual care. Larger, multicenter studies are recommended to confirm this observed benefit seen in this relatively small trial.

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14. SMART-COP: A Better Pneumonia Stratification Score?

This new, simple-to-use score had high sensitivity for predicting need for intensive respiratory or vasopressor support among CAP patients.

Background. Existing severity assessment tools, such as the pneumonia severity index (PSI) and CURB-65 (tool based on confusion, urea level, respiratory rate, blood pressure, and age 65 years), predict 30-day mortality in community-acquired pneumonia (CAP) and have limited ability to predict which patients will require intensive respiratory or vasopressor support (IRVS).

Methods. The Australian CAP Study (ACAPS) was a prospective study of 882 episodes in which each patient had a detailed assessment of severity features, etiology, and treatment outcomes. Multivariate logistic regression was performed to identify features at initial assessment that were associated with receipt of IRVS. These results were converted into a simple points-based severity tool that was validated in 5 external databases, totaling 7464 patients.

Results. In ACAPS, 10.3% of patients received IRVS, and the 30-day mortality rate was 5.7%. The features statistically significantly associated with receipt of IRVS were low systolic blood pressure (2 points), multilobar chest radiography involvement (1 point), low albumin level (1 point), high respiratory rate (1 point), tachycardia (1 point), confusion (1 point), poor oxygenation (2 points), and low arterial pH (2 points): SMART-COP. A SMART-COP score of 3 points identified 92% of patients who received IRVS, including 84% of patients who did not need immediate admission to the intensive care unit. Accuracy was also high in the 5 validation databases. Sensitivities of PSI and CURB-65 for identifying the need for IRVS were 74% and 39%, respectively.

Conclusions. SMART-COP is a simple, practical clinical tool for accurately predicting the need for IRVS that is likely to assist clinicians in determining CAP severity.

Charles PGP, et al. Clinical Infectious Diseases 2008;47:375–384.

15. McCain and Obama on Emergency Care: The Candidates' Approach to Emergency Care

Berger E. Ann Emerg Med. 2008;52:265-267.

…In the turbulent arena of presidential politics, a roiling economy and unrest abroad there are no political certainties. But health care, behind only the economy, has risen to the top of domestic issues for both Senator Barack Obama, the Democratic nominee, as well as Senator John McCain, the Republican nominee. That's largely because health care has increasingly become a serious economic issue stinging the pocketbooks of voters. According to one recent study by Harvard University researchers, every 30 seconds someone files for bankruptcy in the aftermath of a serious health problem. It is fair to say, then, that at some point health care will reach the forefront of the next President's agenda…

To understand the specific views of Barack Obama and John McCain on emergency care, it is helpful to review their overall health care plans…

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16. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study

Henschke N, et al. BMJ 2008;337:a171

Objective: To estimate the one year prognosis and identify prognostic factors in cases of recent onset low back pain managed in primary care.

Design: Cohort study with one year follow-up.

Setting: Primary care clinics in Sydney, Australia.

Participants: An inception cohort of 973 consecutive primary care patients (mean age 43.3, 54.8% men) with non-specific low back pain of less than two weeks’ duration recruited from the clinics of 170 general practitioners, physiotherapists, and chiropractors.

Main outcome measures: Participants completed a baseline questionnaire and were contacted six weeks, three months, and 12 months after the initial consultation. Recovery was assessed in terms of return to work, return to function, and resolution of pain. The association between potential prognostic factors and time to recovery was modelled with Cox regression.

Results: The follow-up rate over the 12 months was more than 97%. Half of those who reduced their work status at baseline had returned to previous work status within 14 days (95% confidence interval 11 to 17 days) and 83% had returned to previous work status by three months. Disability (median recovery time 31 days, 25 to 37 days) and pain (median 58 days, 52 to 63 days) took much longer to resolve. Only 72% of participants had completely recovered 12 months after the baseline consultation. Older age, compensation cases, higher pain intensity, longer duration of low back pain before consultation, more days of reduced activity because of lower back pain before consultation, feelings of depression, and a perceived risk of persistence were each associated with a longer time to recovery.

Conclusions: In this cohort of patients with acute low back pain in primary care, prognosis was not as favourable as claimed in clinical practice guidelines. Recovery was slow for most patients. Nearly a third of patients did not recover from the presenting episode within a year.

17. Antipsychotics Useful in Psychiatric Emergencies, Study Confirms

NEW YORK (Reuters Health) Aug 15 - Immediate control of aggressive and impulsive behavior in psychiatric emergencies can be achieved through administration of antipsychotic medications, findings from an observational study indicate, confirming the validity of current medication practices.

Dr. Stefan Wilhelm and two colleagues from the medical department of Lilly Deutschland GmbH, Bad Homburg, Germany evaluated the short-term effectiveness and tolerability of atypical and typical antipsychotic medications in the emergency treatment of acutely agitated adult patients.

Treatment over the first 5 days was classified according to whether olanzapine, risperidone, or haloperidol was administered, with or without benzodiazepine co-medication.

In the open-access online journal BMC Psychiatry, the investigators report that "clear improvements" in agitation and aggression scores were noted in all treatment groups within the short observation period (5 days).

Most of the 558 patients included in the study had a diagnosis of schizophrenia and large proportions had mental disorders due to psychoactive substance abuse, mood disorders, and adult personality disorders.

Dr. Wilhelm and colleagues also observed that more patients treated with olanzapine (73.8%) were fully alert and active at day 2 than patients treated with risperidone (57.1%) or haloperidol (58.0%). This may have been caused by less frequent use of concomitant benzodiazepines, "suggesting that olanzapine may achieve an effective immediate control of aggression without severe tranquilisation of the patient," they write.

Concomitant benzodiazepines were used in 68.7% of olanzapine-treated patients, versus 72.2% and 83.3% of risperidone- and haloperidol-treated patients, respectively.

Summing up, Dr. Wilhelm and colleagues say this study confirms that "current medication practices for immediate aggression control are effective with positive results present within a few days."

They conclude that "given the huge number of patients requiring emergency inpatient or outpatient treatment for aggressive or impulsive behaviour, the use of atypical antipsychotics such as olanzapine may have the potential to reduce the medical burden for patients with this psychiatric condition."

BMC Psychiatry 2008, 8:61 (22 July 2008)

Full-text (free):

18. Cardiac MR Can Screen for ACS in the Emergency Department

August 12, 2008 (Boston, MA) — Harvard researchers have come up with a new and improved cardiac MR protocol they say can be used in the emergency department to screen for ACS. While other MR protocols have been proposed for this setting in the past, Dr Ricardo C Cury (Harvard Medical School, Boston, MA) and colleagues says theirs has the added advantage of being able to differentiate between new and old MI, providing information over and above clinical assessment and traditional cardiac risk factors.

As Cury explained to heartwire, all imaging modalities that have been used to triage possible ACS patients in the emergency setting--MRI as well as cardiac CT and nuclear perfusion imaging--have struggled to distinguish acute from prior MI. For their study, Cury et al were interested specifically in patients with chest pain, negative cardiac biomarkers, and no ECG changes indicative of acute ischemia.

"The patients in this study were all patients who had been in the emergency department for at least 12 hours waiting for changes in cardiac enzymes and waiting for a stress test," he said. "So by doing MRI early on, we were able to detect myocardial injury before the rise of cardiac enzymes. There were some patients who had increased cardiac enzymes at a later stage, but we were able to detect both edema and necrosis before the increase in cardiac enzymes."

MR Protocol Includes Information on Edema, LV Wall Thinning

In their protocol, Cury et al used T2-weighted imaging to look for myocardial edema and assessment of left ventricular wall thickness to check for myocardial thinning, in addition to first pass perfusion, cine function, and delayed-enhancement MRI. "The beauty of this is the combination of delayed enhancement looking at myocardial necrosis and T2-weighted imaging looking at myocardial edema," Cury explained. "By combining this information, we can differentiate patients with acute vs old MI and which patients had unstable angina vs non-STEMI. Unstable angina is very difficult for different modalities to detect, and we were able to detect it in the great majority of cases," Cury said.

The entire cardiac MR protocol, on average, took just over 30 minutes per patient. A diagnosis of ACS was subsequently confirmed by chart review.

Out of 62 patients presenting with possible ACS symptoms, the new cardiac MR protocol increased the specificity, positive predictive value, and overall accuracy, as compared with the conventional cardiovascular magnetic resonance protocol (which did not include T2-weighted imaging or LV-wall assessment). Cury et al's protocol also significantly improved on information derived from clinical risk assessment alone or from clinical risk assessment combined with traditional cardiac risk factors.

"At this point, just using initial clinical risk assessment based on ECG and cardiac enzymes, we are not doing a great job, and that's why many physicians are just admitting patients for catheterization, or, in some cases, 2% to 4% of patients are discharged when they actually have ACS," he explained. "So we think this is really impressive: MRI remained a significant predictor above and beyond traditional cardiac risk factors and clinical risk assessment. Specifically, if you have a positive MRI, you have 120 times higher likelihood of having ACS as compared with patients with normal MR, after adjusting for traditional cardiac risk factors and clinical risk assessment."

How MR Might Fit In

So how would cardiac MR fit into emergency-room triage? Cury told heartwire that if a patient had a positive stress test, he or she would go directly to the cath lab. If not, the patient could undergo MRI and if this turned up myocardial edema or necrosis or a regional wall-motion abnormality, they, too, could go directly to the cath lab. But patients in whom there is no evidence of myocardial injury could likely be sent home or undergo later stress testing, although Cury emphasized that this proposed strategy would require further, prospective testing.

Cury also clarified that MR might carve out its own niche distinct from cardiac CT, which has increasingly been shown to play an important role in emergency-room triage.

"CT will, I think, be the first-line test in the acute chest pain setting for patients with low likelihood of having ACS, whereas MRI, I believe, will be used more in patients with intermediate likelihood of ACS," he said. "In the future, I can see the emergency physicians stratifying the patient as low, intermediate, or high risk based on risk factors and type of chest pain, etc, and patients with low risk would probably go to CT, whereas in patients with intermediate risk or even high risk but no diagnostic ECG and negative enzymes, MRI would be a better test."

At present, Cury acknowledged, most hospital emergency departments would not have easy access to MR, but down the road, newer acute chest pain and stroke centers might consider including dedicated MR machines.

Circulation, Aug 2008; 118: 837-844.

19. A Double-blind Randomized Clinical Trial Evaluating the Analgesic Efficacy of Ketorolac versus Butorphanol for Patients with Suspected Biliary Colic in the ED

Olsen JC, et al. Acad Emerg Med. 2008;15:718-722.

Objectives: Patients presenting to the emergency department (ED) with suspected biliary colic often require intravenous (IV) analgesia. The choice of IV analgesia typically includes opioids and ketorolac. Although ultrasound (US) is the initial diagnostic study in these patients, nondiagnostic scans and a high clinical suspicion may require the patient to undergo hepatobiliary scintigraphy (HIDA). Opioids such as morphine interfere with the HIDA scan and thus may limit its value as an analgesic in the ED for these patients. Analgesics that do not interfere with HIDA scanning include ketorolac and butorphanol, an opioid agonist–antagonist. This study evaluates the efficacy of IV ketorolac compared to butorphanol for the treatment of biliary colic pain in the ED.

Methods: Between June 2005 and February 2007, a convenience sample of patients presenting to the ED with abdominal pain suspected to be biliary colic were randomized to receive either 30 mg of IV ketorolac or 1 mg of IV butorphanol. Pain level was assessed using a 1 to 10 "faces" visual analog pain scale initially, as well as 15 and 30 minutes after medication infusion. Side effect profiles and the need for rescue analgesia were also assessed. Patients and clinicians were blinded to the study drug given.

Results: Forty-six patients were enrolled in the study. Both groups had similar demographics and baseline pain scores. The mean (±standard deviation [SD]) pain score in the butorphanol group decreased from 7.1 (±1.7) to 2.1 (±2.2) after 30 minutes. The mean (±SD) pain score in the ketorolac group decreased from 7.4 (±2.0) to 3.1 (±3.3) after 30 minutes. Both groups had similar needs for rescue analgesia. Side effects included dizziness and sedation with butorphanol and nausea with ketorolac.

Conclusions: Although limited by small sample size and convenience sample, this study demonstrates that both ketorolac and butorphanol provide pain relief in biliary colic. Both agents should be considered reasonable options in the ED treatment of biliary colic, especially in patients that may undergo HIDA.

20. Physician Clinical Impression Does Not Rule Out Spontaneous Bacterial Peritonitis in Patients Undergoing ED Paracentesis

Chinnock B, et al. Ann Emerg Med. 2008;52:268-273.

Study objective
We determine whether clinical characteristics and physician assessment are useful in the exclusion of spontaneous bacterial peritonitis in emergency department (ED) patients with ascites requiring paracentesis.

We conducted a prospective, observational study of ED patients with ascites undergoing paracentesis. Predefined clinical characteristics including historical features and ED vital signs were recorded. Each patient was assessed by 2 separate, blinded physicians for severity of abdominal tenderness and overall clinical suspicion for spontaneous bacterial peritonitis. The primary outcome measures were sensitivity, specificity, and likelihood ratios (LR) of the individual clinical characteristics and the physician assessments. Spontaneous bacterial peritonitis was defined by absolute neutrophil count greater than 250 cells/mm3 or positive fluid culture result.

There were 285 separate physician assessments in 144 patients enrolled with complete data. Spontaneous bacterial peritonitis was diagnosed in 17 (11.8%) patients. Physician clinical impression had a sensitivity of 76% (95% confidence interval [CI] 62% to 91%) and specificity of 34% (95% CI 28% to 40%) for the detection of spontaneous bacterial peritonitis. The lowest negative LR was associated with the presence of any abdominal pain or tenderness (negative LR=0.4); however, the presence of pain/tenderness was also observed in 85% of patients without spontaneous bacterial peritonitis. Six patients (4.2%) with spontaneous bacterial peritonitis had at least 1 physician assessment of little to no risk for spontaneous bacterial peritonitis, and 3 of the 6 subsequently died during their hospitalization.

Clinical characteristics and physician assessment were insufficient in the diagnosis or exclusion of spontaneous bacterial peritonitis in the ED patient undergoing diagnostic or therapeutic paracentesis. This finding supports routine laboratory fluid analysis after ED paracentesis.