1. 2014 Non-ST
Elevation (NSTE) ACS Clinical Practice Guidelines -- What's New?
New
guidelines were released by the ACC/AHA Sept 23 (reference below). What follows
is an excerpt from Spinler SA’s summary of “what’s new?”
Approximately
30% of patients presenting with acute coronary syndrome (ACS) have ST-segment
elevation myocardial infarction (MI), and the remainder unstable angina or
non--ST-segment elevation (NSTE) MI. Because the presentations of unstable
angina and NSTE MI are similar, the guideline authors of new practice
guidelines updated their terminology to
NSTE ACS, rather than UA/NSTE MI, to reflect this similarity. This complete
revision replaces the 2012 ACCF/AHA focused update incorporated into the 2007
ACCF/AHA guidelines.1 In general, the
approach to the patient remains unchanged: risk stratify, select an initial
management strategy, complete the diagnostic evaluation for MI, use medical
therapy and revascularization in appropriate patients, and initiate secondary
prevention therapies.
Selected
differences between the 2012 combined guideline and the 2014 are described
below. Notably, the authors are to be commended for including new Class I
recommendations for patient discharge instructions as well as the recommendation
for a plan of care for smooth transitions and systems to promote care
coordination. These clear instructions include specific recommendations for
patient education regarding cardiovascular risk factors (blood pressure,
cholesterol levels, lifestyle modification such as exercise and smoking
cessation, medications, management of recurrent angina, cardiovascular risk
factors, and activity levels. The
hospital readmission rate for ACS remains high and having an organized
well-written plan of attack helps hospitals and clinicians take the initiative
to implement multidisciplinary teams to “attack” the problem.
Diagnosis of myocardial infarction:
1. A class
III recommendation: No benefit is given for CK-MB assay for diagnosis of MI
when using contemporary troponin assays and measurement should be reserved for
estimation of infarct size.
2. The
diagnosis of myocardial infarction is made when the troponin rises or falls. If
the initial troponin is elevated (defined as greater than the 99th percentile of
the upper value of the reference range), the diagnosis is made if a ≥ 20% rise
or fall in subsequent troponins occurs.
3. Although
no specific recommendation is made with respect to use of point-of-care
troponins, their lower specificity is acknowledged and central laboratory
testing is favored in addition to initial point-of-care testing.
4. A class
IIb recommendation is made to remeasure troponin on day 3 or 4 to ascertain
infarct size.
5. A class
IIb recommendation is made to add B-type natriuretic peptide (BNP) as an
additional prognostic tool.
Risk stratification:
6. A class
IIa recommendation is given for coronary CT angiography in patients with
possible ACS, a normal 12-lead ECG, negative troponins, and no history of
coronary artery disease CAD.
7. The term
“ischemia-guided strategy” replaces “initial conservative management.” An
ischemia-guided approach is recommended for patients with a low-risk score
(TIMI 0 or 1, GRACE less than 109).
8. The
early invasive strategy recommendations are stratified by timing:
a.
Immediate (within 2 hours): Patients with refractory or recurrent angina with
initial treatment, signs/symptoms of heart failure, new/worsening mitral
regurgitation, hemodynamic instability, sustained ventricular tachycardia, or
ventricular fibrillation
b.
Early (within 24 hours): None of the immediate characteristics but new
ST-segment depression, a GRACE risk score > 140, or temporal change in
troponin
c.
Delayed invasive: None of the immediate or early characteristics but renal
insufficiency, left ventricular ejection fraction (LVEF) less than 40%, early post-infarct angina,
history of percutaneous coronary intervention (PCI) within the past 6 months,
prior coronary artery bypass surgery (CABG), GRACE risk score of 109-140, or
TIMI score of 2 or higher.
More on NSTE
ACS medical therapy and special populations here (full-text free): http://my.americanheart.org/professional/ScienceNews/2014-NSTE-ACS-Clinical-Practice-Guidelines----Whats-New_UCM_466977_Article.jsp
The New Guidelines Themselves
Amsterdam
EA, et al. 2014 AHA/ACC Guideline for the Management of Patients with NSTE ACS:
Executive Summary: A Report of the ACC/AHA Task Force on Practice Guidelines. Circulation.
2014 Sep 23 [Epub ahead of print].
2. Patient
Satisfaction Surveys and Quality of Care: An Information Paper.
Farley H,
et al. Ann Emerg Med. 2014 Mar 20 [Epub ahead of print]
With
passage of the Patient Protection and Affordable Care Act of 2010, payment
incentives were created to improve the "value" of health care delivery.
Because physicians and physician practices aim to deliver care that is both
clinically effective and patient centered, it is important to understand the
association between the patient experience and quality health outcomes. Surveys
have become a tool with which to quantify the consumer experience. In addition,
results of these surveys are playing an increasingly important role in
determining hospital payment. Given that the patient experience is being used
as a surrogate marker for quality and value of health care delivery, we will
review the patient experience-related pay-for-performance programs and effect
on emergency medicine, discuss the literature describing the association
between quality and the patient-reported experience, and discuss future opportunities
for emergency medicine.
Quotes:
“A review
of the current academic literature appears to be divided on the relationship
between the patient experience and objective measures of quality.”
“Review of
HCAHPS data demonstrates that patients’ perception of the quality of nursing
communication is more likely to influence overall patient satisfaction scores
than physician communication.”
“…many,
including the American Medical Association, criticize the use of patient
satisfaction measures as a validated tool for judging physician performance.”
“We believe
that current evidence demonstrates that patient satisfaction is not a validated
proxy for quality and that other more sensitive and specific measures should be
used to determine the quality of health care delivery.”
“Unfortunately,
policymakers and hospital leadership have conflated satisfaction and quality
where the association between a patient’s perception of care and the technical
quality of services rendered and subsequent effect on desired patient outcomes are
not validated.”
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(14)00132-2/fulltext
3. Reducing variation in hospital admissions from the ED for
low-mortality conditions may produce savings.
Sabbatini
AK, et al. Health Aff (Millwood). 2014 Sep 1;33(9):1655-63.
The
emergency department (ED) is now the primary source for hospitalizations in the
United States, and admission rates for all causes differ widely between EDs.
In this
study we used a national sample of ED visits to examine variation in
risk-standardized hospital admission rates from EDs and the relationship of
this variation to inpatient mortality for the fifteen most commonly admitted
medical and surgical conditions. We then estimated the impact of variation on
national health expenditures under different utilization scenarios.
Risk-standardized
admission rates differed substantially across EDs, ranging from 1.03-fold for
sepsis to 6.55-fold for chest pain between the twenty-fifth and seventy-fifth
percentiles of the visits. Conditions such as chest pain, soft tissue
infection, asthma, chronic obstructive pulmonary disease, and urinary tract
infection were low-mortality conditions that showed the greatest variation.
This suggests that some of these admissions might not be necessary, thus
representing opportunities to improve efficiency and reduce health spending.
Our data
indicate that there may be sizeable savings to US payers if differences in ED
hospitalization practices could be narrowed among a few of these
high-variation, low-mortality conditions.
4. Contamination of Environmental Surfaces with Staphylococcus
aureus in Households With Children Infected with MRSA
Fritz SA,
et al. JAMA Pediatr. 2014 September 08 [Epub ahead of print]
Importance Household environmental surfaces may serve as
vectors for the acquisition and spread of methicillin-resistant Staphylococcus
aureus (MRSA) among household members, although few studies have evaluated
which objects are important reservoirs of MRSA.
Objectives To determine the prevalence of environmental
MRSA contamination in households of children with MRSA infection; define the
molecular epidemiology of environmental, pet, and human MRSA strains within
households; and identify factors associated with household MRSA contamination.
Design,
Setting, and Participants Fifty children
with active or recent culture-positive community-associated MRSA infection were
enrolled from 2012 to 2013 at St Louis Children’s Hospital and at community
pediatric practices affiliated with the Washington University Pediatric and
Adolescent Ambulatory Research Consortium in St Louis, Missouri.
Main
Outcomes and Measures Samples of
participants’ nares, axillae, and inguinal folds were cultured to detect S
aureus colonization. Samples of 21 household environmental surfaces, as well as
samples obtained from pet dogs and cats, were cultured. Molecular typing of S
aureus strains was performed by repetitive-sequence polymerase chain reaction
to determine strain relatedness within households.
Results Methicillin-resistant S aureus was recovered
from samples of environmental surfaces in 23 of the 50 households (46%), most
frequently from the participant’s bed linens (18%), television remote control
(16%), and bathroom hand towel (15%). It colonized 12% of dogs and 7% of cats.
At least 1 surface was contaminated with a strain type matching the
participant’s isolate in 20 households (40%). Participants colonized with S
aureus had a higher mean (SD) proportion of MRSA-contaminated surfaces (0.15 [0.17])
than noncolonized participants (0.03 [0.06]; mean difference, 0.12 [95% CI,
0.05-0.20]). A greater number of individuals per 1000 ft2 (93 m2) were also
associated with a higher proportion of MRSA-contaminated surfaces (β = 0.34,
P = .03). The frequency of cleaning household surfaces was not associated with
S aureus environmental contamination.
Conclusions
and Relevance Methicillin-resistant S
aureus strains concordant with infecting and colonizing strains are present on
commonly handled household surfaces, a factor that likely perpetuates MRSA
transmission and recurrent disease. Future studies are needed to determine
methods to eradicate environmental contamination and prevent MRSA transmission
in households.
5. Legal Marijuana and Pediatric Exposure: Pot Edibles
Implicated in Spike in Child ED Visits
Eric Berger.
Ann Emerg Med. 2014;64(4):A19–A21.
On a partly
sunny Friday afternoon in August, the Denver County Fair opened its gates with
the usual attractions one might expect at such gatherings. There were dog
competitions, live music performances, everything you could want on a stick,
and square dancing.
But this
year, the fair, which expected to draw about 20,000 people to the National
Western Complex, decided to add a new exhibit: the Pot Pavilion. In addition to
offering a prize for the “best marijuana plant” there were “speed rolling”
contests, Grateful Dead karaoke, and a best handmade bong contest. The
celebration of pot culture also included an “edibles” category, which included
such foods as brownies. The winning brownie was made of dark chocolate and
walnuts.
This,
perhaps, is where a bit of marijuana’s darker side became apparent. Colorado’s
marijuana legalization has benefited some of the state’s residents, and it’s
certainly proven a major attraction at events such as the Denver County Fair.
There’s also some evidence it has cut crime rates. But the drug’s legalization
has also had some unpleasant adverse effects, perhaps most notably the ease
with which children can now access the product, especially through edibles.
This has resulted in a spike in emergency department (ED) visits for childhood
marijuana exposure.
In shops
throughout the state, adults can purchase a variety of marijuana-infused
goodies, from fudge, cookies, and brownies to hard candies, gelato, and gummy
bears.
“It may be
too late to stem the rush toward legalization of recreational marijuana use and
the proliferation of products that comes with it,” David Sack, MD, chief
executive of Elements Behavioral Health, and a specialist in addiction
medicine, editorialized this summer in the Los Angeles Times. “Instead,” Dr.
Sack wrote, “we need to focus on better ways to protect children, combat the
notion that marijuana is harmless and fund the much-needed additional research
on medical uses for marijuana's chemical components, such as the promising
cannabidiol, which may prove effective without producing a high.”
In a
historic departure from prohibition and punishment for marijuana use,
Colorado’s Amendment 64 passed by a margin of 55% to 45% in 2012, allowing
people aged 21 years or older to grow up to 3 immature and 3 mature cannabis
plants and purchase up to an ounce of marijuana. Use of the drug is permitted
in a manner similar to alcohol, with equivalent offenses to driving under the
influence.
Colorado’s
EDs have been on the front lines of assessing, understanding, and dealing with
the unintended consequences of the state’s new marijuana law, which went into
effect on January 1, 2014. Essentially 3 types of patients have presented to
EDs since the law’s passage.
One of the
groups, according to Andrew A. Monte, MD, an assistant professor of emergency
medicine and medical toxicology at the University of Colorado–Denver and a
toxicologist with the Rocky Mountain Poison and Drug Center, is patients in
whom there’s been an exacerbation of chronic conditions, such as a seriously
ill asthma patient coming in because he or she smoked marijuana.
A second
group is patients who have acute effects from eating too many edibles, with
conditions such as very fast pulse rates, hallucinations, or cyclic vomiting.
EDs have also treated patients who have burns associated with making butane
hash oil, a potent and increasingly popular form of marijuana known for a
giving a quick high.
“In general
when there’s increased availability of a drug, then there [are] increased
health care encounters associated with that drug,” Dr. Monte said. “Let me
quantify the amount of burden we’ve seen so far. It is not enormous. At the
University of Colorado hospital, for example, I think we will see several
patients on the weekend. For the most part, they are not overrunning the ED,
and for the most part, they are easily treated with fluids and they go home.”
For the
rest of the article (free): http://www.annemergmed.com/article/S0196-0644(14)01154-8/fulltext
6. In-hospital mortality following treatment with RBC
transfusion or inotropic therapy during EGDT for septic shock: a retrospective
propensity-adjusted analysis.
Mark DG, et
al. Crit Care. 2014 Sep 12;18(5):496. [Epub ahead of print]
Introduction:
We sought to investigate whether treatment of subnormal (less than 70%) central
venous oxygen saturation (ScvO2) with inotropes or red blood cell (RBC)
transfusion during early goal-directed therapy (EGDT) for septic shock is
independently associated with in-hospital mortality.
Methods: Retrospective
analysis of a prospective EGDT patient database drawn from 21 emergency
departments with a single standardized EGDT protocol. Patients were included
if, during EGDT, patients concomitantly achieved a central venous pressure
(CVP) of ≥8 mm Hg and a mean arterial pressure (MAP) of ≥65 mm Hg while
registering a ScvO2 less than 70%. Treatment propensity scores for either RBC
transfusion or inotrope administration were separately determined from
independent patient sub-cohorts. Propensity-adjusted logistic regression
analyses were conducted to test for associations between treatments and
in-hospital mortality.
Results: Of
2595 EGDT patients, 572 (22.0%) met study inclusion criteria. The overall
in-hospital mortality rate was 20.5%. Inotropes or RBC transfusions were
administered for an ScvO2 less than 70% to 51.9% patients. Patients were not
statistically more likely to achieve an ScvO2 of ≥70% if they were treated with
RBC transfusion alone (29/59, 49.2%, P=0.19), inotropic therapy alone (104/226,
46.0%, P=0.15) or both RBC and inotropic therapy (7/12, 58.3%, P=0.23) as
compared to no therapy (108/275, 39.3%). Following adjustment for treatment
propensity score, RBC transfusion was associated with a decreased adjusted odds
ratio (aOR) of in-hospital mortality among patients with hemoglobin values less
than 10 g/dL (aOR 0.42, 95% CI 0.18-0.97, P=0.04) while inotropic therapy was
not associated with in-hospital mortality among patients with hemoglobin values
of 10 g/dL or greater (aOR 1.16, 95% CI 0.69 to 1.96, P=0.57).
Conclusions:
Among patients with septic shock treated with EGDT in the setting of subnormal
ScvO2 values despite meeting CVP and MAP target goals, treatment with RBC
transfusion may be independently associated with decreased in-hospital
mortality.
7. Automated UA and Urine Dipstick in the Emergency Evaluation
of Young Febrile Children
Kanegaye
JT, et al. Pediatr 2014;134:523-529.
OBJECTIVE:
The performance of automated flow cytometric urinalysis is not well described
in pediatric urinary tract infection. We sought to determine the diagnostic
performance of automated cell counts and emergency department point-of-care
(POC) dipstick urinalyses in the evaluation of young febrile children.
METHODS: We
prospectively identified a convenience sample of febrile pediatric emergency
department patients less than 48 months of age who underwent urethral
catheterization to obtain POC and automated urinalyses and urine culture.
Receiver operating characteristic analyses were performed and diagnostic
indices were calculated for POC dipstick and automated cell counts at different
cutpoints.
RESULTS: Of
342 eligible children, 42 (12%) had urinary bacterial growth ≥50 000/mL. The
areas under the receiver operating characteristic curves were: automated white
blood cell count, 0.97; automated bacterial count, 0.998; POC leukocyte
esterase, 0.94; and POC nitrite, 0.76. Sensitivities and specificities were 86%
and 98% for automated leukocyte counts ≥100/μL and 98% and 98% for bacterial
counts ≥250/μL. POC urine dipstick with ≥1+ leukocyte esterase or positive
nitrite had a sensitivity of 95% and a specificity of 98%. Combinations of
white blood cell and bacterial counts did not outperform bacterial counts
alone.
CONCLUSIONS:
Automated leukocyte and bacterial counts performed well in the diagnosis of
urinary tract infection in these febrile pediatric patients, but POC dipstick
may be an acceptable alternative in clinical settings that require rapid
decision-making.
8. The proper way to go AMA: 8 Elements to Address
By Matthew
DeLaney, MD; Acad Life in Emerg Med, January 13th, 2014.
Case
Example: 42 y/o male presents with right lower quadrant abdominal pain and has
significant tenderness at McBurney’s point on exam. While waiting for a CT scan
to evaluate for possible appendicitis the patient rips out his IV and tells the
nurse “I’m leaving, I don’t want to sit here all night, and you can’t make me
stay.” The nurse pulls you out of another room and hands you the standard
against medical advice (AMA) paperwork.
Leaving AMA
In 1992,
about 0.1% of patients seen in the Emergency Department (ED) left AMA. In the
years since, this number has increased significantly with recent studies
showing that up to 2% of ED patients leave AMA. These patients pose a
particular challenge for ED providers from both a diagnostic and risk
management standpoint.
Risks to
the Patient
From a
medical standpoint, patients who leave AMA tend to have an increased risk of
having an adverse outcome. Baptist et al. found that asthma patients who left
AMA had an increased risk of both relapse and subsequent ICU admissions [1].
Similarly patients with chest pain who left AMA had a higher risk of myocardial
infarction than other patients with similar characteristics who stayed in the
ED to complete their workup [2].
Risks to
the Provider
Patients
who leave against medical advice are up to 10x more likely to sue the emergency
physician when compared to other ED patients. Some estimate that 1 in 300 AMA
cases results in a lawsuit compared to 1 in 30,000 standard ED visits [3].
While
posing a particular challenge to providers, there are several basic steps that
can be taken when dealing with a patient leaving AMA that can help improve
patient outcomes while providing significant medicolegal protection to the
providers.
How to do
it properly…
9. Lactulose vs PEG 3350-Electrolyte Solution for Treatment of
Overt Hepatic Encephalopathy: The HELP RCT
Rahimi RS,
et al. JAMA Intern Med. 2014 September 22 [Epub ahead of print]
Importance Hepatic encephalopathy (HE) is a common cause
of hospitalization in patients with cirrhosis. Pharmacologic treatment for
acute (overt) HE has remained the same for decades.
Objective To compare polyethylene glycol
3350–electrolyte solution (PEG) and lactulose treatments in patients with
cirrhosis admitted to the hospital for HE. We hypothesized that rapid catharsis
of the gut using PEG may resolve HE more effectively than lactulose.
Design,
Setting, and Participants The HELP
(Hepatic Encephalopathy: Lactulose vs Polyethylene Glycol 3350-Electrolyte
Solution) study is a randomized clinical trial in an academic tertiary hospital
of 50 patients with cirrhosis (of 186 screened) admitted for HE.
Interventions Participants were block randomized to receive
treatment with PEG, 4-L dose (n = 25), or standard-of-care lactulose (n = 25)
during hospitalization.
Main
Outcomes and Measures The primary end
point was an improvement of 1 or more in HE grade at 24 hours, determined using
the hepatic encephalopathy scoring algorithm (HESA), ranging from 0 (normal
clinical and neuropsychological assessments) to 4 (coma). Secondary outcomes
included time to HE resolution and overall length of stay.
Results A total of 25 patients were randomized to
each treatment arm. Baseline clinical features at admission were similar in the
groups. Thirteen of 25 patients in the standard therapy arm (52%) had an
improvement of 1 or more in HESA score, thus meeting the primary outcome
measure, compared with 21 of 23 evaluated patients receiving PEG (91%) (P less
than .01); 1 patient was discharged before final analysis and 1 refused
participation. The mean (SD) HESA score at 24 hours for patients receiving
standard therapy changed from 2.3 (0.9) to 1.6 (0.9) compared with a change
from 2.3 (0.9) to 0.9 (1.0) for the PEG-treated groups (P = .002). The median
time for HE resolution was 2 days for standard therapy and 1 day for PEG
(P = .01). Adverse events were uncommon, and none was definitely study related.
Conclusions
and Relevance PEG led to more rapid HE
resolution than standard therapy, suggesting that PEG may be superior to
standard lactulose therapy in patients with cirrhosis hospitalized for acute
HE.
10. No Appointment Necessary? Ethical Challenges in Treating
Friends and Family
Gold KJ, et
al. N Engl J Med 2014; 371:1254-1258.
Physicians
may be asked or choose to provide medical care to family members or to give
informal or undocumented care to friends, neighbors, or colleagues who are not
their patients. Treatment can range from refilling a prescription, discussing a
recent injury, or ordering a test to performing major surgeries. The ethical
risks of caring for relatives or friends or providing informal and undocumented
care are substantial but may be overlooked. Although there may be limited
situations in which providing medical treatment for friends and family is
acceptable, these situations are often nuanced. We review guidance from
professional medical organizations, summarize research on the prevalence and
attitudes about physicians' treatment of friends and family, and review the
ethical issues and offer guidance for making decisions about when to provide
care…
Ethical
Guidance from Professional Organizations
Not all
medical organizations have issued guidelines on this topic. However, all those
that have published guidelines recommend against care for self or family other
than in exceptional situations, and we are aware of no professional
organization that condones this practice. The very first code of medical ethics
drafted by the American Medical Association (AMA) in 1847 recommended against
physicians treating family members, stating that “the natural anxiety and
solicitude which he [the physician] experiences at the sickness of a wife, a
child . . . tend to obscure his judgment, and produce timidity and irresolution
in his practice.”1
The 1993
guidelines of the AMA Code of Medical Ethics state that physicians “generally
should not treat themselves or members of their immediate families.”2 The code
describes many potential pitfalls in the care of family members, including
failure to ask about sensitive areas of the medical history or social
situation, avoiding important or sensitive aspects of the physical examination,
a lack of professional objectivity, conflict among roles with potential
complications if the medical care does not go well, practicing outside the
scope of training, the possibility that the patient will not be forthcoming,
and lack of informed consent and assent by the patient. The American College of
Physicians recently updated its ethical principles and asserted that physicians
should “usually not enter into the dual relationship of physician-family member
or physician-friend.”3 Similarly, the American Academy of Pediatrics states
that “caring for one's own children presents significant ethical issues.”4 All
these organizations recognize that there may be minor care or emergency
situations for which no other physician is available in which acute and limited
care may be appropriate.
Prevalence
and Attitudes
In several
studies assessing the prevalence of medical treatment of friends or family by
physicians, there is a substantial gap between what professional organizations
recommend and what physicians actually do. A 1993 survey of physician-parents
in Iowa reported that 4% of children had a parent as the physician of record,
and two thirds of these physicians prescribed medications for their child.5 A
1991 study showed that 99% of surveyed physicians reported having received
requests from family members for medical advice, diagnosis, or treatment, and
83% had prescribed medications for relatives.6 Physicians cite convenience as a
key reason to provide this care, but other explanations have included a wish to
save the relative money as well as a belief that “I provide the best care.”7
The actual
treatments that physicians provide to friends and family range dramatically
from acute and minor care to care for serious chronic illnesses and invasive
procedures.6,8 In one study, 15% of hospital physicians reported serving as the
attending for a loved one, and 9% had performed elective surgery on a
relative.6 Although most surveys suggest medications such as antibiotics,
birth-control pills, and analgesics are the most commonly prescribed drugs in
these encounters, there are substantial numbers of prescriptions for
antidepressants, sedatives, narcotic pain medications, and other addictive
substances.8-10 Studies have shown that physicians often feel pressured and
conflicted about requests to treat friends and family and that most physicians
have declined at least one request or indicated that they would consider
declining, as observed in clinical vignettes.11,12
On the
basis of our clinical experience, we developed three realistic case vignettes
as examples of different types of care a physician might be asked or tempted to
provide to family members or friends…
11. Images in Clinical Practice
Elderly
Male with Abdominal Pain
Young Woman
with Abdominal Pain
Superior
Vena Cava Syndrome
Aortic
Dissection
Congenital
Duodenal Obstruction and Double-Bubble Sign
12. Prophylactic Antibiotics for Epistaxis: Where’s the
Evidence?
by Brian Cohn, MD. Emergency Physicians Monthly,
September 16, 2014
One more
case of unnecessary antibiotic administration? Check the research.
Epistaxis
is a common problem, with a lifetime incidence of about 60% (Gifford 2008).
While the majority of cases do not require medical attention, epistaxis remains
a common presenting complaint in the ED. The management of epistaxis can be
highly variable, with the most frequently utilized technique being nasal
packing with either coagulant impregnated balloons, nasal tampons, or petroleum
gauze.
The role of
prophylactic systemic antibiotics when anterior nasal packing is employed
remains highly controversial. Concern for the development of toxic shock
syndrome (TSS) seems to have motivated the clinical recommendations of the
authors of the American College of Emergency Physicians 2009 Focus on Treatment
of Epistaxis, who noted that while direct evidence is lacking, “most sources
recommend TMP/SMX, cephalexin, or amoxicillin/clavulanic acid to prevent
sinusitis and toxic shock syndrome [TSS].” But this serious complication is exceedingly
rare. The incidence of TSS with nasal packing following nasal surgery is
approximately 16.5 in 100,000, or 1 in approximately 6000 cases (Jacobson
1986). But there have been no cases of toxic shock syndrome reported in the
literature following nasal packing for epistaxis. Of 61 cases of TSS identified
in the Minneapolis-St. Paul area between 2000 and 2006, none were attributed to
an upper respiratory source (Devries 2011).
American
EPs seemed to adopt the conservatism of their British counterparts who, when
surveyed in 2005, revealed that 78% of interviewees believed that the use of
prophylactic antibiotics with anterior nasal packing reduced the incidence of
infection (Biswas 2006). But there seemed to be scant evidence that this was
actually true. One large randomized trial evaluating the use of prophylactic
antibiotics with nasal packing following septoplasty found no difference in
post-operative pain, infectious symptoms, or the amount of purulent nasal
discharge with or without prophylactic antibiotics (Ricci 2012).
The
applicability of these results to patients with anterior nasal packing for
epistaxis is unclear. While site of packing (anterior vs. posterior), sterility
of the environment (operative room vs. ED), and entry into nasal cavity
(post-surgical vs. non-instrumented) may have some effect on the incidence of
infectious outcomes, the overall effectiveness of antibiotics in epistaxis
patients who have undergone anterior nasal packing remains unclear.
Unfortunately,
no randomized controlled trials evaluating the effect of antibiotics on
outcomes following epistaxis could be identified. What evidence does exist,
however, suggests that antibiotics are unnecessary and potentially harmful. One
prospective observational trial showed that anterior nasal packing and
antibiotic administration had no effect on the microbiological flora of the
nasal cavity following epistaxis (Biswas 2009). Folllowing removal of anterior
nasal packs, patients had bacterial cultures sent from nasal swabs from both
nares. The microbiological results were similar for both packed and unpacked
sides, and were similar between those patients who received antibiotics and
those who did not.
Antibiotics
also seem to have no effect on patient outcomes. One study of 149 patients
showed no infectious complications (sinusitis, otitis, toxic shock syndrome) in
patients who underwent anterior nasal packing regardless of whether they
received antibiotics (Pepper 2012). Another study compared infectious symptoms
in patients undergoing anterior nasal packing before and after instituting a
protocol to reduce antibiotic use. While antibiotic use decreased from 74% of
patients to 16% of patients, there was no difference in infectious symptoms
between the groups at 6-week telephone follow-up (Biggs 2013). No patient in
either of these studies developed otitis media or sinusitis…
The
remainder of the review (free): http://www.epmonthly.com/features/current-features/prophylactic-antibiotics-for-epistaxis-where-s-the-evidence/
13. Suspected Ureteral Colic: US or CT?
1. Ultrasonography versus CT for
suspected nephrolithiasis.
Smith-Bindman
R, et al. N Engl J Med. 2014 Sep 18;371(12):1100-10.
BACKGROUND:
There is a lack of consensus about whether the initial imaging method for
patients with suspected nephrolithiasis should be computed tomography (CT) or
ultrasonography.
METHODS: In
this multicenter, pragmatic, comparative effectiveness trial, we randomly
assigned patients 18 to 76 years of age who presented to the emergency
department with suspected nephrolithiasis to undergo initial diagnostic
ultrasonography performed by an emergency physician (point-of-care
ultrasonography), ultrasonography performed by a radiologist (radiology
ultrasonography), or abdominal CT. Subsequent management, including additional
imaging, was at the discretion of the physician. We compared the three groups
with respect to the 30-day incidence of high-risk diagnoses with complications
that could be related to missed or delayed diagnosis and the 6-month cumulative
radiation exposure. Secondary outcomes were serious adverse events, related
serious adverse events (deemed attributable to study participation), pain
(assessed on an 11-point visual-analogue scale, with higher scores indicating
more severe pain), return emergency department visits, hospitalizations, and
diagnostic accuracy.
RESULTS: A
total of 2759 patients underwent randomization: 908 to point-of-care
ultrasonography, 893 to radiology ultrasonography, and 958 to CT. The incidence
of high-risk diagnoses with complications in the first 30 days was low (0.4%)
and did not vary according to imaging method. The mean 6-month cumulative
radiation exposure was significantly lower in the ultrasonography groups than
in the CT group (P less than 0.001). Serious adverse events occurred in 12.4%
of the patients assigned to point-of-care ultrasonography, 10.8% of those
assigned to radiology ultrasonography, and 11.2% of those assigned to CT
(P=0.50). Related adverse events were infrequent (incidence, 0.4%) and similar
across groups. By 7 days, the average pain score was 2.0 in each group
(P=0.84). Return emergency department visits, hospitalizations, and diagnostic
accuracy did not differ significantly among the groups.
CONCLUSIONS:
Initial ultrasonography was associated with lower cumulative radiation exposure
than initial CT, without significant differences in high-risk diagnoses with
complications, serious adverse events, pain scores, return emergency department
visits, or hospitalizations. (Funded by the Agency for Healthcare Research and
Quality.).
2. Associated editorial: Imaging in
the ED for Suspected Nephrolithiasis
Curhan
G. N Engl J Med 2014; 371:1154-1155.
The
excruciating pain of renal colic often drives the affected patient to the
emergency department. Given the increasing prevalence of nephrolithiasis,1 more
patients than ever before are arriving for evaluation and treatment — nearly 1
million emergency department visits for upper-tract stone disease per year.2 In
the emergency department, rapid diagnosis should facilitate the most appropriate
therapy.
Patients
with a previous episode of colic will often make the diagnosis themselves, but
those who have renal colic for the first time rarely do. Laboratory tests are
nondiagnostic. The urine sediment will occasionally reveal crystals, but more
commonly there will be nonspecific findings of leukocyturia and hematuria.
Diagnostic certainty typically rests on imaging studies. A plain radiograph of
the kidneys, ureters, and bladder is neither sensitive nor specific and does
not provide information about other potentially important diagnoses.
Ultrasonography and computed tomography (CT) each have advantages and
disadvantages. The advantages of ultrasonography include the fact that the
patient is not exposed to radiation and the possibility that the imaging can be
performed at the bedside, but ultrasonography is less sensitive than CT for
identifying the number and size of kidney stones and rarely identifies the
location of a ureteral stone. CT has been widely considered to be the best
available imaging method for diagnosis because it can detect stones as small as
1 mm, provides information on location and possibly composition, and detects
the presence of other asymptomatic stones. However, CT is more expensive than
ultrasonography and exposes the patient to radiation. A common belief is that
CT leads to more rapid diagnosis, thereby reducing the time spent in the
emergency department.
The report
by Smith-Bindman and colleagues in this issue of the Journal 3 provides
valuable information about the choice of the first imaging study for patients
presenting to the emergency department with suspected nephrolithiasis. The
strengths of the study include its multicenter, randomized, pragmatic design
and the large sample size and excellent retention rate. Participants were
randomly assigned to undergo ultrasonography performed by an emergency
physician (point-of-care ultrasonography), ultrasonography performed by a
radiologist, or abdominal CT, but the treating physician could order additional
imaging studies if clinically indicated. Among patients with suspected
nephrolithiasis, the clinical outcomes did not differ substantially according
to the first imaging method used, but the ultrasonography group had lower
cumulative radiation exposure. Although ultrasonography was not as sensitive as
CT when used initially, the diagnostic accuracy for nephrolithiasis among
patients who were randomly assigned initially to ultrasonography was
essentially the same as that among patients assigned initially to CT.
Several issues
should be considered in the interpretation of this important study. The
diagnosis of nephrolithiasis was based either on the patient's report of stone
passage or on a medical record that a stone was surgically removed. Because
many patients pass their stone after an episode of renal colic without actually
seeing the stone, their reports could have been influenced by the information
given by the emergency department providers, thereby increasing the apparent
diagnostic accuracy of the imaging studies.
Interpretation
of the ultrasound examination could have been influenced by the patient's
history and by previous imaging. It is possible that the characteristic
shadowing or hydronephrosis would have been more likely to be reported in a
patient with a history of stone disease, particularly if a recent imaging study
had identified a stone. This latter possibility is supported by the study's
findings that among persons in the ultrasonography groups, those with a history
of nephrolithiasis were less likely than those without such a history to
undergo subsequent CT. In addition, there is no mention in the article about
whether a patient had had a recent stone-related procedure, which would also
greatly influence the probability that a diagnosis of nephrolithiasis would be
made.
On the
basis of the study findings, it is reasonable for a physician to use
ultrasonography as the initial imaging method for a patient presenting to the
emergency department with suspected nephrolithiasis, remembering that
additional imaging studies should be used when clinically indicated. Although
CT had higher sensitivity than ultrasonography, this increased sensitivity did
not lead to better clinical outcomes. Importantly, patients assigned to
ultrasonography performed by a radiologist actually spent more time in the
emergency department than did patients in either of the other two groups,
supporting the long-held belief that CT would lead to quicker disposition
(although the length of stay with point-of-care ultrasonography was similar to
that with CT).
Although we want to limit radiation exposure from all sources,
the decision to use ultrasonography needs to be balanced against the additional
information obtained by CT, which may influence subsequent clinical decisions.
For example, additional renal stones may be seen on CT but not on
ultrasonography, leading to a more aggressive regimen to prevent new stone
formation. It should be emphasized, as the authors note, that ultrasonography
when used alone is not very sensitive for detecting stones; more than 40% of
stones were not detected by initial ultrasonography. However, the approach of
starting with ultrasonography and then proceeding to CT if indicated resulted
in similar levels of sensitivity in the three groups. It is reassuring that
high-risk diagnoses were rarely missed with this approach.
In the
future, the wider use of low-dose CT,4-6 which exposes the patient to
substantially less radiation than conventional CT, may change the risk–benefit
balance of these imaging methods, but low-dose CT will need to be examined as
carefully as the imaging methods in the current study. Regardless of which
imaging method is used, providers should remember to tell their patients that
new stone formation can be prevented and to give them preventive strategies
that should reduce the number of future emergency department visits for renal
colic.
14. Evaluation of Acute Appendicitis by Pediatric Emergency
Physician Sonography
Sivitz AB,
et al. Ann Emerg Med. 2014;64:358–364.e4
Study
objective: We investigate the accuracy of pediatric emergency physician
sonography for acute appendicitis in children.
Methods: We
prospectively enrolled children requiring surgical or radiology consultation
for suspected acute appendicitis at an urban pediatric emergency department.
Pediatric emergency physicians performed focused right lower-quadrant
sonography after didactics and hands-on training with a structured scanning
algorithm, including the graded-compression technique. We compared their
sonographic interpretations with clinical and radiologic findings, as well as
clinical outcomes as defined by follow-up or pathologic findings.
Results: Thirteen
pediatric emergency medicine sonographers performed 264 ultrasonographic
studies, including 85 (32%) in children with pathology-verified appendicitis.
Bedside sonography had a sensitivity of 85% (95% confidence interval [CI] 75%
to 95%), specificity of 93% (95% CI 85% to 100%), positive likelihood ratio of
11.7 (95% CI 6.9 to 20), and negative likelihood ratio of 0.17 (95% CI 0.1 to
0.28).
Conclusion:
With focused ultrasonographic training, pediatric emergency physicians can
diagnose acute appendicitis with substantial accuracy.
15. Emergency Hospitalizations for Unsupervised Prescription
Medication Ingestions by Young Children.
Lovegrove
MC, et al. Pediatrics. 2014 Sep 15 [Epub ahead of print]
BACKGROUND:
Emergency department visits and subsequent hospitalizations of young children
after unsupervised ingestions of prescription medications are increasing
despite widespread use of child-resistant packaging and caregiver education
efforts. Data on the medications implicated in ingestions are limited but could
help identify prevention priorities and intervention strategies.
METHODS: We
used nationally representative adverse drug event data from the National
Electronic Injury Surveillance System-Cooperative Adverse Drug Event
Surveillance project and national retail pharmacy prescription data from IMS
Health to estimate the frequency and rates of emergency hospitalizations for
unsupervised prescription medication ingestions by young children (2007-2011).
RESULTS: On
the basis of 1513 surveillance cases, 9490 estimated emergency hospitalizations
(95% confidence interval: 6420-12 560) occurred annually in the United States
for unsupervised prescription medication ingestions among children aged less
than 6 years from 2007 through 2011; 75.4% involved 1- or 2-year old children.
Opioids (17.6%) and benzodiazepines (10.1%) were the most commonly implicated
medication classes. The most commonly implicated active ingredients were
buprenorphine (7.7%) and clonidine (7.4%). The top 12 active ingredients, alone
or in combination with others, were implicated in nearly half (45.0%) of
hospitalizations. Accounting for the number of unique patients who received
dispensed prescriptions, the hospitalization rate for unsupervised ingestion of
buprenorphine products was significantly higher than rates for all other
commonly implicated medications and 97-fold higher than the rate for oxycodone
products (200.1 vs 2.1 hospitalizations per 100 000 unique patients).
CONCLUSIONS:
Focusing unsupervised ingestion prevention efforts on medications with the
highest hospitalization rates may efficiently achieve large public health
impact. From 2007
to 2011, more than 9,000 children younger than age 6 were hospitalized each
year for accidentally taking prescription medications, according to a study in
the journal Pediatrics. Among the adult prescription drugs implicated in
childhood poisonings, buprenorphine had the highest rate of emergency
hospitalizations.
Related ABC news report
9,000 children hospitalized for Rx
drug poisonings annually in U.S.
An
anti-addiction drug used to fight the nation's heroin and painkiller abuse
epidemics poses a threat to young children who accidentally swallow relatives'
prescriptions, a federal study says. Some children have died.
The study
found that the drug, buprenorphine, was the adult prescription medication most
commonly implicated in emergency hospitalizations of children aged 6 and
younger.
For every
100,000 patients prescribed buprenorphine, 200 young children were hospitalized
for taking it, the study found. That rate is more than four times higher than
the statistic for next most commonly implicated drug, a blood pressure
medicine. Almost 800 youngsters a year were hospitalized after swallowing
buprenorphine, the study found.
The rest of
the essay: http://abcnews.go.com/Health/wireStory/kids-poisonings-linked-anti-addiction-medicine-25502178
16. Lack of improved outcomes with increased use of targeted
temperature management following out-of-hospital cardiac arrest: A multicenter
retrospective cohort study.
Mark DG, et
al. Resuscitation. 2014;85:1549- 1556.
STUDY AIMS:
To assess whether increased use of targeted temperature management (TTM) within
an integrated healthcare delivery system resulted in improved rates of good
neurologic outcome at hospital discharge (Cerebral Performance Category score
of 1 or 2).
METHODS: Retrospective
cohort study of patients with OHCA admitted to 21 medical centers between
January 2007 and December 2012. A standardized TTM protocol and educational
program were introduced throughout the system in early 2009. Comatose patients
eligible for treatment with TTM were included. Adjusted odds of good neurologic
outcome at hospital discharge and survival to hospital discharge were assessed
using multivariate logistic regression.
RESULTS: A
total of 1119 patients were admitted post-OHCA with coma, 59.1% (661 of 1119)
of which were eligible for TTM. The percentage of patients treated with TTM
markedly increased during the study period: 10.5% in the years preceding
(2007-2008) vs. 85.1% in the years following (2011-2012) implementation of the
practice improvement initiative. However, unadjusted in-hospital survival
(37.3% vs. 39.0%, p=0.77) and good neurologic outcome at hospital discharge
(26.3% vs. 26.6%, p=1.0) did not change. The adjusted odds of survival to
hospital discharge (AOR 1.0, 95% CI 0.85-1.17) or a good neurologic outcome
(AOR 0.94, 95% CI 0.79-1.11) were likewise non-significant.
INTERPRETATION:
Despite a marked increase in TTM rates across hospitals in an integrated
delivery system, there was no appreciable change in the crude or adjusted odds
of in-hospital survival or good neurologic outcomes at hospital discharge among
eligible post-arrest patients.
Full-text: http://authors.elsevier.com/a/1Pn0e14RWFrLzx
Full-text: http://authors.elsevier.com/a/1Pn0e14RWFrLzx
17. Review: Most anti-clotting drugs are comparable in safety
A study in JAMA
compared the safety outcomes from nearly 50 trials of eight blood-thinning
regimens. Apixaban use for three months was associated with a 0.28% chance of
major bleeding, the lowest rate among the treatments studied. Rivaroxaban was
associated with a 0.49% risk, compared to risks of about 0.89% for the other
treatments.
18. Ketamine and Intraocular Pressure in Children.
Wadia S, et
al. Ann Emerg Med. 2014;64(4):385–388.e1.
STUDY
OBJECTIVE: We determine the increase in intraocular pressure during pediatric
procedural sedation with ketamine, and the proportion of children whose
increase might be clinically important (at least 5 mm Hg).
METHODS: We
prospectively enrolled children aged 8 to 18 years, chosen to receive ketamine
sedation in a pediatric emergency department. We measured intraocular pressure
before sedation, immediately after ketamine administration, 2 minutes post-drug
administration, and every 5 minutes thereafter until recovery or 30 minutes
after the final dose. We descriptively report our observations.
RESULTS:
For the 60 children enrolled, the median intraocular pressure increase was 3 mm
Hg (range 0 to 8 mm Hg). Fifteen children had a brief greater than or equal to
5 mm Hg increase in intraocular pressure from baseline.
CONCLUSION:
In this study of ketamine sedation in children with healthy eyes, we observed
mild increases in intraocular pressure that at times transiently exceeded our
bounds for potential clinical importance (5 mm Hg).
19. NSAIDs Are a Major Cause of Anaphylaxis-Related ED Visits
David J.
Amrol, MD. Journal Watch Emerg Med September 16, 2014
Epinephrine
is first-line treatment for drug-induced anaphylaxis, but it is underutilized.
Anaphylaxis
is a life-threatening hypersensitivity reaction that can be allergic or
nonallergic. Allergic causes of drug-induced anaphylaxis generally are IgE
mediated (e.g., hives and angioedema within 1 hour of penicillin
administration), whereas in nonallergic anaphylaxis, inflammatory mediators are
released by nonspecific immunological mechanisms (e.g., leukotrienes in
aspirin-associated respiratory disease, with reactions delayed up to 2–3
hours). In this study, researchers assessed the rate of anaphylaxis among 806
patients who presented to a Brazilian emergency department with drug-induced
hypersensitivity reactions.
Of 117
patients who met criteria for anaphylaxis, culprit drugs were identified in
76%. Almost 50% of reactions were caused by nonsteroidal anti-inflammatory
drugs (NSAIDs), followed by latex (12%), antibiotics (4%), and neuromuscular
blockers, radiocontrast agents, and midazolam (3% combined). All NSAID
reactions were nonallergic, and most featured urticaria or angioedema and
bronchospasm or dyspnea; reactions to antibiotics, hypnotics, neuromuscular
blockers, and latex were mostly IgE mediated. IgE-mediated reactions were more
severe and involved in all cases of cardiogenic shock. Only 34% of patients
with moderate-to-severe anaphylaxis received epinephrine in the emergency
department.
Comment:
Physicians should be aware that medications can cause both allergic and
nonallergic anaphylactic reactions. Although the most severe reactions
involving cardiogenic shock are IgE mediated, non–IgE-mediated causes such as
NSAIDs and radiocontrast still are life-threatening and actually might be more
common. Epinephrine is underutilized: Regardless of cause or mechanism, it is
always first-line treatment for anaphylaxis.
Citation:
Aun MV et al. Nonsteroidal anti-inflammatory drugs are major causes of
drug-induced anaphylaxis. J Allergy Clin Immunol Pract 2014 Jul/Aug; 2:414.
20. US EDs: Timely Care and LOS Studies
1. Timeliness of Care in US EDs: An
Analysis of Newly Released Metrics From the Centers for Medicare & Medicaid
Services
Le ST, et
al. JAMA Intern Med. 2014 September 15 [Epub ahead of print]
Introduction
The
relationship between increasing emergency department (ED) crowding and worse
outcomes for patients has been well documented.1,2 This evidence has created
growing recognition among federal policy makers that the quality of emergency
care should be measured. In July 2013, the Centers for Medicare & Medicaid
Services3 made several quality measures of ED timeliness publicly available online.
These data provide a national portrait of the ability of EDs to provide timely
care, an essential concern given the severity and time sensitivity of many
acute illnesses and injuries.
We
investigated how hospital EDs perform on measurements of timely care and
whether certain hospital characteristics or patient populations are associated
with poor timeliness of ED care. Previous literature on ED timeliness of care
has been limited to investigations with non–nationally representative samples
or to 1 or 2 measures of timeliness of care.1,4- 7
Results
(excerpt)
Our sample
consisted of 3692 hospitals with EDs that reported at least 1 ED measure to the
Centers for Medicare & Medicaid Services. Most were nonteaching (72.1%),
private nonprofit (63.4%) hospitals located in urban areas (52.2%). For
patients discharged from the ED, the median wait time to see a health care
professional was approximately half an hour, and the length of stay was just
over 2 hours. For admitted patients, the median length of stay in the ED was
more than 4 hours, approximately one-third of which was accounted for by
boarding time. Extreme variability existed for all measures…
Discussion
Our
findings provide a crucial starting point for discussion on the status quo of
ED quality and on ED quality metrics. Given the variation in hospital ED
performance, our results suggest a potential for improvement in ED timeliness.
However, if these measures are translated into pay-for-performance incentives,
the financial pressures faced by larger, urban, major teaching, public
hospitals may be exacerbated.
2. Association Between ED Length of Stay and Rates of Admission to Inpatient and Observation
Services
Carrier E,
et al. JAMA Intern Med. 2014 September 15 [Epub ahead of print]
Introduction
In the
United States, quality measures have recently been developed to evaluate
emergency department (ED) length of stay (LOS). As of 2012, hospitals are
expected to report their median ED LOS to the Centers for Medicare and Medicaid
Services, which reports these data to the public on their Hospital Compare
database.1 However, a concern is that, in the future, maximum LOS intervals
will be tied to reimbursements; such measures could lead to adverse
consequences, including rising numbers of brief admissions, as have been
observed in other nations with similar programs.
Results
(excerpt)
Most visits
(51.9%) resulting in admission were to hospitals that met the 8-hour target for
90% of admissions, while only 22.5% of visits resulting in discharge were to
hospitals that met the 4-hour target for 90% of discharges (Table 1). Visits to
hospitals that met the 8-hour targets for admitted patients had higher adjusted
odds of inpatient admission. Visits to hospitals that met the 4-hour targets
for discharged patients had no significantly different odds of admission than
visits to hospitals that did not.
Discussion
The results
of our analysis do not mirror the experience of some countries that have
adopted formal LOS guidelines, where observation admissions were most
affected2- 4,8,9; however, they demonstrate an association between ED LOS and
rates of admissions to inpatient services. These cross-sectional findings do
not illustrate the precise nature of this association, but they suggest that
potential associations between LOS targets and admission decisions may merit
further investigation before EDs are rewarded for achieving specific targets on
LOS quality measures. Emergency department patients require varied services,
and an LOS that is adequate for one patient may be insufficient for the
evaluation of another. If the pressure of LOS measures encourages otherwise
avoidable inpatient admissions, this could increase health care costs and
unnecessary hospital-acquired conditions. Policy makers should consider these
unintended consequences before adopting ED LOS quality measures.
21. Patient Flow in the ED: A Classification and Analysis of
Admission Process Policies.
Kang H, et
al. Ann Emerg Med. 2014;64(4):335–342.e8.
STUDY
OBJECTIVE: We investigate the effect of admission process policies on patient
flow in the emergency department (ED).
METHODS: We
surveyed an advisory panel group to determine approaches to admission process
policies and classified them as admission decision is made by the team of
providers (attending physicians, residents, physician extenders) (type 1) or
attending physicians (type 2) on the admitting service, team of providers (type
3), or attending physicians (type 4) in the ED. We developed discrete-event
simulation models of patient flow to evaluate the potential effect of the 4
basic policy types and 2 hybrid types, referred to as triage attending
physician consultation and remote collaborative consultation on key performance
measures.
RESULTS:
Compared with the current admission process policy (type 1), the alternatives
were all effective in reducing the length of stay of admitted patients by 14%
to 26%. In other words, patients may spend 1.4 to 2.5 hours fewer on average in
the ED before being admitted to internal medicine under a new admission process
policy. The improved flow of admitted patients decreased both the ED length of
stay of discharged patients and the overall length of stay by up to 5% and
6.4%, respectively. These results are framed in context of teaching mission and
physician experience.
CONCLUSION:
An efficient admission process can reduce waiting times for both admitted and
discharged ED patients. This study contributed to demonstrating the potential
value of leveraging admission process policies and developing a framework for
pursuing these policies.
22. Do Glucocorticoids Provide Benefit to Children With
Bronchiolitis?
Ng C, et
al. Ann Emerg Med. 2014;64(4):389-391.
Bottom-line:
The use of systemic or inhaled glucocorticoids in children aged 2 years or
younger with acute bronchiolitis does not decrease admission rate or length of
hospitalization.
23. Micro Lit Bits
A. Rural family physicians more
likely to provide ER, urgent care
A study
found 8% of family physicians in frontier settings and 3% of those in urban
areas spent at least 80% of their time providing emergency or urgent care,
according to researchers at the Robert Graham Center for Policy Studies in
Family Medicine and Primary Care. Graham Center medical director for health
policy Kathleen Klink, M.D., commented that the results were not surprising
because rural physicians tend to have a broader scope of practice. The study
was published in the Journal of the American Board of Family Medicine.
B. Experts issue framework for
managing sickle cell disease
A National
Heart, Lung, and Blood Institute panel co-chaired by family physician Barbara
Yawn, M.D., has released updated recommendations for managing sickle cell
disease in children and adults. The guidelines, published in JAMA, advise daily
oral penicillin until age 5, vaccination against pneumonia as early as age 6
weeks and annual transcranial Doppler for ages 2 to 16. Adults who experience
at least three serious blood flow crises in a year should be treated with
hydroxyurea, which the guidelines say is also suitable for children.
C. Are weight-loss supplements
counterproductive?
The use of
weight-loss supplements may encourage counterproductive eating habits. In this study, women who were taking a
supposed weight-loss supplement ate more unhealthy foods at a buffet than those
aware they were receiving a placebo. This may help explain why the growing use
of weight-loss supplements does not seem to be contributing to a reduction in
weight.
D. Health Confidence: A Simple,
Essential Measure for Patient Engagement and Better Practice
Asking
patients this one question can lead to better outcomes.
Wasson J,
et al. Fam Pract Manag. 2014 Sep-Oct;21(5):8-12.
E. Aerobic exercise improves
children's attention, mood
Among
children at risk for attention-deficit/hyperactivity disorder, aerobic
exercises before the beginning of the school day led to greater improvements in
attention and mood than sedentary classroom activities, U.S. researchers found.
Aerobic physical activity also benefited typically developing children, according
to the study in the Journal of Abnormal Child Psychology.
F. Study shows placebo may work as
well as antidepressant
A
University of California, Los Angeles, study found little difference in
clinical outcomes between patients given an antidepressant drug or a placebo,
but both therapies led to better results than supportive care alone. Lead
investigator Andrew Leuchter, M.D., said the efficacy in both the placebo and
antidepressant arms of the study may be due to participants' belief that the
treatment will be effective. The findings were published in the British Journal
of Psychiatry.
G. HHS: Hospitals to save $5.7B
because more people have insurance
HHS
estimated U.S. hospitals will save $5.7 billion in 2014 because of fewer unpaid
bills for uninsured patients who now have coverage through the Affordable Care
Act. About 74% of the savings will be in states that have expanded their
Medicaid programs.
Kaiser
Health News: http://www.kaiserhealthnews.org/Stories/2014/September/24/hospitals-uncompensated-care-aca-obamacare-medicaid.aspx
H. Nonprescription racemic
epinephrine for asthma
In this
study, the authors sought to determine the dose of Inhaled racepinephrine (RE)
that is equivalent to nebulized albuterol. Inhaled racepinephrine
(Asthmanefrin®) became available in September 2012 as a non-prescription
treatment for bronchospasm. The authors report on four adult subjects with
mild, stable asthma that completed a series of methacholine challenges on
different days. A significant dose response for RE was noted, but the
bronchoprotection from methacholine provided by RE was significantly less than
that provided by albuterol. The authors concluded that RE may be less effective
than albuterol in treating acute bronchospasm.
I. U.S. sees decline in new diabetes
cases, CDC finds
CDC
officials found the number of new diabetes cases in the U.S. declined to 7.1
per 1,000 people in 2012, following an increase from 3.2 per 1,000 people in
1990 to 8.8 per 1,000 people in 2008. However, researchers noted a persistent
increase among Hispanics, blacks and those with lower education levels. The
findings were published in the Journal of the American Medical Association.
J. Study links healthy lifestyles to
reduced heart attack risk in men
A study in
the Journal of the American College of Cardiology says practicing five healthy
behaviors, including exercising and drinking moderately, could save 4 in 5
middle-aged and older men from possible heart attacks. Compared with overweight
patients and those who ate poorly, exercised little, drank too much alcohol and
smoked, participants who followed the recommended health behaviors were 86%
less likely to experience heart attacks.
K. Care coordination cuts hospital
admissions, ED visits, for frequent fliers
Canadian
researchers found patients who were recipients of a care coordination quality
improvement strategy had a 20% decline in hospitalizations compared with those
in the standard care cohort. Data also showed care coordination initiatives
resulted in 31% fewer emergency department visits among older patients. The
findings appear in the Canadian Medical Association Journal.
Full-text
(free): http://www.cmaj.ca/content/early/2014/09/15/cmaj.140289.full.pdf+html
