1. Empirical Anti-MRSA Therapy Not Supported for non-ICU
patients with CAP
The low
prevalence (0.1%) of MRSA CAP among patients not admitted to an ICU provides
support for the current Infectious Diseases Society of America and American
Thoracic Society CAP guidelines, which do not recommend routine
anti-MRSA antibiotics for patients admitted to a general medical floor. Among
patients admitted to an intensive care unit, MRSA CAP prevalence was 2.7%.
Self WH, et
al. Clin Infect Dis. 2016 May 8 [Epub ahead of print].
Background. Prevalence
of Staphylococcus aureus community-acquired pneumonia (CAP) and its clinical
features remain incompletely understood, complicating empirical selection of
antibiotics.
Methods. Using
a multicenter, prospective surveillance study of adults hospitalized with CAP,
we calculated the prevalence of methicillin-resistant S. aureus (MRSA) and
methicillin-susceptible S. aureus (MSSA) among all CAP episodes. We compared
the epidemiologic, radiographic, and clinical characteristics of S. aureus CAP
(per respiratory or blood culture) with those of pneumococcal (per respiratory
or blood culture or urine antigen) and all-cause non-S. aureus CAP using
descriptive statistics.
Results. Among
2259 adults hospitalized for CAP, 37 (1.6%) had S. aureus identified, including
15 (0.7%) with MRSA and 22 (1.0%) with MSSA; 115 (5.1%) had Streptococcus
pneumoniae. Vancomycin or linezolid was administered to 674 (29.8%) patients
within the first 3 days of hospitalization. Chronic hemodialysis use was more
common among patients with MRSA (20.0%) than pneumococcal (2.6%) and all-cause
non-S. aureus (3.7%) CAP. Otherwise, clinical features at admission were
similar, including concurrent influenza infection, hemoptysis, multilobar
infiltrates, and prehospital antibiotics. Patients with MRSA CAP had more
severe clinical outcomes than those with pneumococcal CAP, including intensive
care unit admission (86.7% vs 34.8%) and in-patient mortality (13.3% vs 4.4%).
Conclusions. Despite
very low prevalence of S. aureus and, specifically, MRSA, nearly one-third of
adults hospitalized with CAP received anti-MRSA antibiotics. The clinical
presentation of MRSA CAP overlapped substantially with pneumococcal CAP,
highlighting the challenge of accurately targeting empirical anti-MRSA
antibiotics with currently available clinical tools and the need for new
diagnostic strategies.
2007
Guidelines: Infectious Diseases Society of America/American Thoracic Society
Consensus Guidelines on the Management of Community-Acquired Pneumonia in
Adults
Full-text
(free): http://cid.oxfordjournals.org/content/44/Supplement_2/S27.full
Moran GJ, et
al. Emergency management of community-acquired bacterial pneumonia: what is new
since the 2007 Infectious Diseases Society of America/American Thoracic Society
guidelines. Am J Emerg Med. 2013
Mar;31(3):602-12.
2. Intensive Blood-Pressure Lowering (to SBP 110-139)
Ineffective in Patients with Acute Cerebral Hemorrhage.
Qureshi AI, et
al; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials
Network. N Engl J Med. 2016 Jun 8 [Epub ahead of print]
Background
Limited data are available to guide the choice of a target for the systolic
blood-pressure level when treating acute hypertensive response in patients with
intracerebral hemorrhage.
Methods We
randomly assigned eligible participants with intracerebral hemorrhage (volume,
below 60 cm3) and a Glasgow Coma Scale (GCS) score of 5 or more (on a scale
from 3 to 15, with lower scores indicating worse condition) to a systolic
blood-pressure target of 110 to 139 mm Hg (intensive treatment) or a target of
140 to 179 mm Hg (standard treatment) in order to test the superiority of
intensive reduction of systolic blood pressure to standard reduction;
intravenous nicardipine to lower blood pressure was administered within 4.5
hours after symptom onset. The primary outcome was death or disability
(modified Rankin scale score of 4 to 6, on a scale ranging from 0 [no symptoms]
to 6 [death]) at 3 months after randomization, as ascertained by an investigator
who was unaware of the treatment assignments.
Results Among
1000 participants with a mean (±SD) systolic blood pressure of 200.6±27.0 mm Hg
at baseline, 500 were assigned to intensive treatment and 500 to standard
treatment. The mean age of the patients was 61.9 years, and 56.2% were Asian.
Enrollment was stopped because of futility after a prespecified interim
analysis. The primary outcome of death or disability was observed in 38.7% of
the participants (186 of 481) in the intensive-treatment group and in 37.7%
(181 of 480) in the standard-treatment group (relative risk, 1.04; 95%
confidence interval, 0.85 to 1.27; analysis was adjusted for age, initial GCS
score, and presence or absence of intraventricular hemorrhage). Serious adverse
events occurring within 72 hours after randomization that were considered by
the site investigator to be related to treatment were reported in 1.6% of the
patients in the intensive-treatment group and in 1.2% of those in the
standard-treatment group. The rate of renal adverse events within 7 days after
randomization was significantly higher in the intensive-treatment group than in
the standard-treatment group (9.0% vs. 4.0%, P=0.002).
Conclusions
The treatment of participants with intracerebral hemorrhage to achieve a target
systolic blood pressure of 110 to 139 mm Hg did not result in a lower rate of
death or disability than standard reduction to a target of 140 to 179 mm Hg.
3. Routine Midazolam Administration Prior to Nasogastric Tube
Insertion in the ED Decreases Patients' Pain
Manning CT,
et al. Acad Emerg Med. 2016 Jul;23(7):766-71
OBJECTIVES:
Patients report pain and discomfort with nasogastric tube (NGT) intubation. We
tested the hypothesis that premedication with midazolam alleviates pain during
NGT placement in the emergency department (ED) by greater than 13 on a 100-mm
visual analog scale (VAS).
METHODS: We
performed a double-blind randomized controlled pilot study, assigning ED
patients requiring NGT placement to midazolam or placebo. All patients received
intranasal cophenylcaine; additionally, they received an intravenous (IV) dose
of the study drug, either 2 mg of IV midazolam or saline control. Nurses placed
NGTs while observed by research staff, who then interviewed subjects to
determine the primary outcome of pain using a VAS. Additional data collected
from patients and their nurses included discomfort during the procedure,
difficulty of tube insertion, and complications.
RESULTS: We
enrolled 23 eligible patients and obtained complete data in all: 10 midazolam
and 13 controls. We found a significant reduction in mean pain VAS score of -31
(95% confidence interval = -53 to -9 mm) with 2 mg of midazolam (mean ± SD = 52
± 30 mm), compared to placebo (mean ± SD = 21 ± 18 mm), more than double the
effect size considered clinically relevant. Treatment did not impact ease of
placement and there were no serious adverse effects.
CONCLUSIONS:
Premedication with 2 mg of IV midazolam reduces pain of NGT insertion in ED
patients without the need for full procedural sedation.
4. Working up the ED CP Patient
A.
Multicenter Evaluation of a 0-Hour/1-Hour Algorithm in the Diagnosis of MI With
High-Sensitivity Cardiac Trop T
Mueller C, et
al. Ann Emerg Med 2016;68(1):76–87.e4
STUDY
OBJECTIVE: We aim to prospectively validate the diagnostic accuracy of the
recently developed 0-h/1-h algorithm, using high-sensitivity cardiac troponin T
(hs-cTnT) for the early rule-out and rule-in of acute myocardial infarction.
METHODS: We
enrolled patients presenting with suspected acute myocardial infarction and
recent (less than 6 hours) onset of symptoms to the emergency department in a
global multicenter diagnostic study. Hs-cTnT (Roche Diagnostics) and sensitive
cardiac troponin I (Siemens Healthcare) were measured at presentation and after
1 hour, 2 hours, and 4 to 14 hours in a central laboratory. Patient triage
according to the predefined hs-cTnT 0-hour/1-hour algorithm (hs-cTnT below 12
ng/L and Δ1 hour below 3 ng/L to rule out; hs-cTnT at least 52 ng/L or Δ1 hour
at least 5 ng/L to rule in; remaining patients to the "observational
zone") was compared against a centrally adjudicated final diagnosis by 2
independent cardiologists (reference standard). The final diagnosis was based
on all available information, including coronary angiography and echocardiography
results, follow-up data, and serial measurements of sensitive cardiac troponin
I, whereas adjudicators remained blinded to hs-cTnT.
RESULTS: Among
1,282 patients enrolled, acute myocardial infarction was the final diagnosis
for 213 (16.6%) patients. Applying the hs-cTnT 0-hour/1-hour algorithm, 813
(63.4%) patients were classified as rule out, 184 (14.4%) were classified as
rule in, and 285 (22.2%) were triaged to the observational zone. This resulted
in a negative predictive value and sensitivity for acute myocardial infarction
of 99.1% (95% confidence interval [CI] 98.2% to 99.7%) and 96.7% (95% CI 93.4%
to 98.7%) in the rule-out zone (7 patients with false-negative results), a
positive predictive value and specificity for acute myocardial infarction of
77.2% (95% CI 70.4% to 83.0%) and 96.1% (95% CI 94.7% to 97.2%) in the rule-in
zone, and a prevalence of acute myocardial infarction of 22.5% in the
observational zone.
CONCLUSION: The
hs-cTnT 0-hour/1-hour algorithm performs well for early rule-out and rule-in of
acute myocardial infarction.
B.
Effectiveness of EDACS vs ADAPT Accelerated Diagnostic Pathways for CP: A
Pragmatic RCT Embedded Within Practice
Than MP, et
al. Ann Emerg Med. 2016;68:93–102.e1
Study
objective
A 2-hour
accelerated diagnostic pathway based on the Thrombolysis in Myocardial
Infarction score, ECG, and troponin measures (ADAPT-ADP) increased early
discharge of patients with suspected acute myocardial infarction presenting to
the emergency department compared with standard care (from 11% to 19.3%).
Observational studies suggest that an accelerated diagnostic pathway using the
Emergency Department Assessment of Chest Pain Score (EDACS-ADP) may further
increase this proportion. This trial tests for the existence and size of any
beneficial effect of using the EDACS-ADP in routine clinical care.
Methods
This was a
pragmatic randomized controlled trial of adults with suspected acute myocardial
infarction, comparing the ADAPT-ADP and the EDACS-ADP. The primary outcome was
the proportion of patients discharged to outpatient care within 6 hours of
attendance, without subsequent major adverse cardiac event within 30 days.
Results
Five hundred
fifty-eight patients were recruited, 279 in each arm. Sixty-six patients
(11.8%) had a major adverse cardiac event within 30 days (ADAPT-ADP 29;
EDACS-ADP 37); 11.1% more patients (95% confidence interval 2.8% to 19.4%) were
identified as low risk in EDACS-ADP (41.6%) than in ADAPT-ADP (30.5%). No
low-risk patients had a major adverse cardiac event within 30 days (0.0% [0.0%
to 1.9%]). There was no difference in the primary outcome of proportion
discharged within 6 hours (EDACS-ADP 32.3%; ADAPT-ADP 34.4%; difference −2.1%
[−10.3% to 6.0%], P=.65).
Conclusion
There was no
difference in the proportion of patients discharged early despite more patients
being classified as low risk by the EDACS-ADP than the ADAPT-ADP. Both
accelerated diagnostic pathways are effective strategies for chest pain
assessment and resulted in an increased rate of early discharges compared with
previously reported rates.
C.
The (questionable) incremental value of stress testing in patients with acute CP
beyond serial cardiac troponin testing
Aldous S, et
al. Emerg Med J 2016;33:319-324
Objective In
patients with acute chest pain and normal range cardiac troponin (cTn),
accurate risk stratification for acute coronary syndrome is challenging. This
study assesses the incremental value of stress testing to identify patients for
angiography with a view to revascularisation.
Methods A
single-centre observational study recruited patients with acute chest pain in
whom serial cTn tests were negative and stress testing (exercise tolerance
testing/dobutamine stress echocardiography) was performed. Stress tests were
reported as negative, non-diagnostic or positive. The primary outcomes were
revascularisation on index admission, or cardiac death and myocardial
infarction over 1 year follow-up.
Results Of
749 patients recruited, 709 underwent exercise tolerance testing and 40 dobutamine
stress echo of which 548 (73.2%) were negative, 169 (22.6%) were non-diagnostic
and 32 (4.3%) were positive. Patients with positive tests (n=19 (59.4%)) were
more likely to undergo index admission revascularisation than patients with
non-diagnostic (n=15 (8.9%)) (p less than 0.001) tests who in turn were more
likely undergo index admission revascularisation than those with negative tests
(n=2 (0.4%)) (p less than 0.001). The risks of adverse events including
cardiovascular death/acute myocardial infarction were low and were similar
across stress test outcomes.
Conclusions
The incremental value of stress testing was the identification of an additional
34 (4.5% (95% CI 3.0% to 6.0%)) patients who underwent index admission
revascularisation with a view to preventing future adverse events. Uncertainty in whether revascularisation
prevents adverse events in patients with negative cTn means the choice to
undertake stress testing depends on whether clinicians perceive value in
identifying 4.5% of these patients for revascularisation.
5. Antiemetics for ED patients with undifferentiated abdominal
pain or acute gastroenteritis
A.
Parenteral antiemetics are as good as placebo or IV fluids—but costlier and
with more side effects
Drugs for the treatment of nausea and
vomiting in adults in the ED setting.
Furyk JS, et
al. Cochrane Database Syst Rev. 2015 Sep 28;(9):CD010106.
BACKGROUND: Nausea
and vomiting is a common and distressing presenting complaint in emergency
departments (ED). The aetiology of nausea and vomiting in EDs is diverse and
drugs are commonly prescribed. There is currently no consensus as to the
optimum drug treatment of nausea and vomiting in the adult ED setting.
OBJECTIVES: To
provide evidence of the efficacy and safety of antiemetic medications in the
management of nausea and vomiting in the adult ED setting.
SEARCH
METHODS: We searched the Cochrane Central Register of Controlled Trials
(CENTRAL; 2014, Issue 8), MEDLINE (OvidSP) (January 1966 to August 2014),
EMBASE (OvidSP) (January 1980 to August 2014) and ISI Web of Science (January
1955 to August 2014). We also searched relevant clinical trial registries and
conference proceedings.
SELECTION
CRITERIA: We included randomized controlled trials (RCTs) of any drug in the
treatment of nausea and vomiting in the treatment of adults in the ED. Study
eligibility was not restricted by language or publication status.
DATA
COLLECTION AND ANALYSIS: Two review authors independently performed study
selection, data extraction and assessment of risk of bias in included studies.
We contacted authors of studies to obtain missing information if required.
MAIN RESULTS:
We included eight trials, involving 952 participants, of which 64% were women.
Included trials were generally of adequate quality, with six trials at low risk
of bias, and two trials at high risk of bias. Three trials with 518
participants compared five different drugs with placebo; all reported the
primary outcome as mean change in visual analogue scale (VAS) (0 to 100) for
nausea severity from baseline to 30 minutes. Trials did not routinely report
other primary outcomes of the change in nausea VAS at 60 minutes or number of
vomiting episodes. Differences in mean VAS change from baseline to 30 minutes
between placebo and the drugs evaluated were: metoclopramide (three trials, 301
participants; mean difference (MD) -5.27, 95% confidence interval (CI) -11.33
to 0.80), ondansetron (two trials, 250 participants; MD -4.32, 95% CI -11.20 to
2.56), prochlorperazine (one trial, 50 participants; MD -1.80, 95% CI -14.40 to
10.80), promethazine (one trial, 82 participants; MD -8.47, 95% CI -19.79 to
2.85) and droperidol (one trial, 48 participants; MD -15.8, 95% CI -26.98 to
-4.62). The only statistically significant change in baseline VAS to 30 minutes
was for droperidol, in a single trial of 48 participants. No other drug was
statistically significantly superior to placebo. Other included trials
evaluated a drug compared to "active controls" (alternative
antiemetic). There was no convincing evidence of superiority of any particular
drug compared to active control. All trials included in this review reported
adverse events, but they were variably reported precluding meaningful pooling
of results. Adverse events were generally mild, there were no reported serious
adverse events. Overall, the quality of the evidence was low, mainly because
there were not enough data.
AUTHORS'
CONCLUSIONS: In an ED population, there is no definite evidence to support the
superiority of any one drug over any other drug, or the superiority of any drug
over placebo. Participants receiving placebo often reported clinically
significant improvement in nausea, implying general supportive treatment such
as intravenous fluids may be sufficient for the majority of people. If a drug
is considered necessary, choice of drug may be dictated by other considerations
such as a person's preference, adverse-effect profile and cost. The review was
limited by the paucity of clinical trials in this setting. Future research
should include the use of placebo and consider focusing on specific diagnostic
groups and controlling for factors such as intravenous fluid administered.
B.
Isopropyl Alcohol Nasal Inhalation Improves Nausea in ED Patients at 10 minutes
Beadle KL, et
al. Ann Emerg Med. 2016;68(1):1-9.e1.
Study objective:
We compare nasal inhalation of isopropyl alcohol versus placebo in treating
nausea among emergency department (ED) patients.
Methods: A
convenience sample of adults with chief complaints of nausea or vomiting was
enrolled in a randomized, double-blind, placebo-controlled trial conducted in
an urban tertiary care ED. Patients were randomized to nasally inhaled
isopropyl alcohol versus nasally inhaled normal saline solution. Patient nausea
and pain were measured with previously published 11-point verbal numeric
response scale scores; patient satisfaction was measured by a 5-point Likert
scale. The primary outcome was reduction in nausea 10 minutes poststart.
Secondary outcomes included patient satisfaction and pain reduction measured at
10 minutes poststart.
Results: Of
84 recruited patients, 80 (95.2%) completed the study. Thirty-seven (46.3%)
received nasally inhaled isopropyl alcohol and 43 (53.8%) received nasally
inhaled normal saline solution. At 10 minutes postintervention, median nausea
verbal numeric response scale score was 3 in the isopropyl alcohol arm versus 6
in the placebo arm, for an effect size of 3 (95% confidence interval 2 to 4).
Median satisfaction score was 4 in the isopropyl alcohol arm versus 2 in the
placebo arm, for an effect size of 2 (95% confidence interval 2 to 2). There
were no significant differences between the 2 arms in median pain verbal
numeric response scale scores or subsequent receipt of rescue antiemetics.
Conclusion: We
found that nasally inhaled isopropyl alcohol achieves increased nausea relief
compared with placebo during a 10-minute period.
How the
investigators describe the intervention: "Study investigators instructed
subjects to nasally inhale from their assigned pad at study start, 2 minutes,
and 4 minutes. At each of these 3 points, subjects were instructed to take deep
inhalations for no more than 60 seconds through their nose. During these deep
inhalations, subjects were instructed to hold their pad 2.5 cm from their nose.
If at any time subjects’ nausea became completely relieved, they were
instructed not to take further deep inhalations. No subjects were permitted any
inhalation therapy after the 4-minute period."
6. Isolated Calf Vein Thrombosis
A.
Should we be looking for and treating isolated calf vein thrombosis?
Horner D, et
al. Emerg Med J 2016;33:431-437
Management of
isolated calf deep vein thrombosis is an area of significant international
debate and variable clinical practice. Both therapeutic anticoagulation and
conservative management carry risk. As clinical care of suspected and confirmed
venous thromboembolic disease increasingly becomes the remit of emergency
medicine, complex decisions are left to practising clinicians at the front
door. We aim to provide a contemporary overview of recent evidence on this
topic and associated challenges facing clinicians. Given the lack of high-level
evidence, we present this work as a narrative review, based on structured
literature review and expert opinion.
A decision to
manage calf thrombosis is principally dependent on the risk of complications
without treatment balanced against the risks of therapeutic anticoagulation.
Estimates of the former risks taken from systematic review, meta-analysis,
observational cohort and recent pilot trial evidence include proximal
propagation 7%–10%, pulmonary embolism 2%–3% and death less than 1%. Fatal
bleeding with therapeutic anticoagulation stands at less than 0.5%, and major
bleeding at approximately 2%. Estimates of haemorrhagic risk are based on
robust data from large prospective management studies of venous thromboembolic
disease; the risks of untreated calf deep vein thrombosis are based on small
cohorts and therefore less exact.
Pending
further trial evidence, these risks should be discussed with patients openly,
in the context of personal preference and shared decision-making.
Anticoagulation may maximally benefit those patients with extensive and/or
symptomatic disease or those with higher risk for complication (unprovoked,
cancer-associated or pregnancy).
B.
ED Management of Suspected Calf-Vein DVT: A Diagnostic Algorithm
Kitchen L, et
al. West J Emerg Med 2016;17(4):384
Introduction:
Unilateral leg swelling with suspicion of deep venous thrombosis (DVT) is a
common emergency department (ED) presentation. Proximal DVT (thrombus in the
popliteal or femoral veins) can usually be diagnosed and treated at the initial
ED encounter. When proximal DVT has been ruled out, isolated calf-vein deep
venous thrombosis (IC-DVT) often remains a consideration. The current standard
for the diagnosis of IC-DVT is whole-leg vascular duplex ultrasonography
(WLUS), a test that is unavailable in many hospitals outside normal business
hours. When WLUS is not available from the ED, recommendations for managing
suspected IC-DVT vary. The objective is to use current evidence and
recommendations to (1) propose a diagnostic algorithm for ICDVTwhen definitive
testing (WLUS) is unavailable; and (2) summarize the controversy surrounding
IC-DVTtreatment.
Discussion:
The Figure combines D-dimer testing with serial CUS or a single deferred FLUS
for the diagnosis of IC-DVT. Such an algorithm has the potential to safely
direct the management of suspected IC-DVT when definitive testing is
unavailable. Whether or not to treat diagnosed IC-DVT remains widely debated
and awaiting further evidence.
Conclusion:
When IC-DVT is not ruled out in the ED, the suggested algorithm, although not
prospectively validated by a controlled study, offers an approach to diagnosis
that is consistent with current data and recommendations. When IC-DVT is
diagnosed, current references suggest that a decision between anticoagulation
and continued follow-up outpatient testing can be based on shared
decision-making. The risks of proximal progression and life-threatening
embolization should be balanced against the generally more benign natural
history of such thrombi, and an individual patient’s risk factors for both
thrombus propagation and complications of anticoagulation.
Full-text
(free): http://escholarship.org/uc/item/4ct8w9j1
7. Quick Lit Reviews from Ann Emerg Med
A.
What Is the Most Effective Treatment of Herpes Simplex Keratitis?
Take-Home
Message
Treatment of
herpes simplex virus keratitis can be accomplished with either topical
trifluridine or ganciclovir, which have similar efficacy. Oral acyclovir is an
acceptable treatment option in cases for which compliance with a topical
ophthalmic regimen may be of concern.
B.
Is Passive Leg Raise an Accurate Diagnostic Method for Assessing Fluid
Responsiveness in Adults?
Take-Home
Message
Transthoracic
echocardiography and passive leg-raise maneuvers can be used to assess preload
responsiveness in the critically ill.
C.
Utility of Central Venous Pressure as a Predictor of Fluid Responsiveness
Take-Home
Message
Existing
evidence suggests that central venous pressure poorly predicts fluid
responsiveness in acute and critically ill patients.
D.
What Is the Significance of Elevated Troponin in Patients With Suspected Acute
Coronary Syndrome and Chronic Kidney Disease?
Take-Home
Message
Patients with
suspected acute coronary syndrome with elevated troponin level in the setting
of chronic kidney disease have a worse prognosis than patients with normal
troponin levels.
8. The Use of ED Holding (ED Transition) Orders to Reduce ED
Length of Stay.
Haydar SA, et
al. Acad Emerg Med. 2016 Jul;23(7):776-85.
OBJECTIVE:
The objective was to evaluate the effect of an emergency clinician-initiated
"ED admission holding order set" on emergency department (ED)
treatment times and length of stay (LOS). We further describe the impact of a
performance improvement strategy with sequential plan-do-study-act (PDSA) cycles
used to influence the primary outcome measures, ED LOS, and disposition
decision to patient gone (DDTPG) time, for admitted patients.
METHODS: We
developed and implemented an expedited, emergency physician-facilitated
admission protocol that bypassed typical inpatient workflows requiring
inpatient evaluations prior to the placement of admission orders. During the
48-month study period, ED flow metrics generated during the care of 27,580
admissions from the 24-month period prior to the intervention were compared to
the 29,978 admissions that occurred during the 24-month period following the
intervention. The intervention was the result of an in-depth, five-phase PDSA
cycle quality improvement intervention evaluating ED flow, which identified the
requirement of bedside inpatient evaluations prior admission order placement as
being a "non-value-added" activity. ED output flow metrics evaluating
the admission process were tracked for 24 months following the intervention and
were compared to the 24 months prior.
RESULTS: The
use of an emergency physician-initiated admission holding order protocol
resulted in sustainable reductions in ED LOS when comparing the 2 years prior
to the intervention, with median LOS of 410 (interquartile range [IQR] = 295 to
543) and 395 (IQR = 283 to 527) minutes, to the 2 calendar years following the
intervention, with the median LOS of 313 (IQR = 21 to 431) and 316 (IQR = 224
to 438) minutes, respectively. This overall reduction in ED LOS of nearly 90
minutes was found to be primarily the result of a decrease in the time from the
emergency physician's admitting DDTPG times with median times of 219 (IQR = 150
to 306) and 200 (IQR = 136 to 286) minutes for the 2 years prior to the
intervention compared to 89 (IQR = 58 to 138) and 92 (IQR = 60 to 147) minutes
for the 2 years following the intervention. It is notable that there was a
modest increase in the door to disposition decision of admission times during
this same study period with annual medians of 176 (IQR = 112 to 261) and 178 (IQR
= 129 to 316) minutes, respectively, for the 2 years prior to 207 (IQR = 129 to
316) and 202 (IQR = 127 to 305) minutes following the intervention.
CONCLUSIONS:
We conclude that the use of emergency physician-initiated holding orders can
lead to marked reductions in ED LOS for admitted patients. Continued
improvement can be demonstrated with an effective performance improvement
initiative designed to continuously optimize the process change.
9. Addressing Social Determinants of Health from the ED through
Social Emergency Medicine
Anderson ES,
et al. West J Emerg Med 2016;17(4):487-9.
Dialogue and
policy surrounding healthcare reform have drawn increasing interest to the
social factors, accountable for nearly one-third of annual deaths in the United
States,1 that affect the health of populations. The Affordable Care Act (ACA) includes
provisions for health systems to address social determinants of health, but how
this is to be accomplished remains uncertain. If we are to make progress as a
health system in addressing social determinants of health, we must open a dialogue
and practice that reaches patients at the front lines of the medical system and
population health – including in the emergency department (ED). The fact that
emergency physicians care for patients who are complicated both medically and
socially is no surprise, but the idea that we have an important role to play in
the social determinants of health of our patients is, while controversial,
gaining increasing attention among emergency physicians across the country.
This interest comes largely from necessity, as we face a daunting task of
providing care to the large volume of vulnerable patients who seek refuge in
our EDs.
The ED is a
window into the community, which starkly frames the contributions of the social
determinants underlying the trauma resuscitations, repeat child visits for
asthma exacerbation, or sepsis due to delay in seeking care. In the ED, we
diagnose and treat the medical problem – but in order to improve the health of our
patients we need to expand our role to diagnose and treat their social
determinants of health as well. We urge our colleagues to not only consider the
social determinants underlying health and illness, but to also develop
systematic interventions, measure their effects, collaborate with others, and
advocate for policies that will improve the health of our patients. We advocate
physicians to address the social determinants of health from the ED, in other words,
to practice Social Emergency Medicine…
For the
remainder of the essay, full-text (free): http://escholarship.org/uc/item/9wz8j32t
10. Images in Clinical Practice
Male With
Pain in Right Calf
Woman With
Pain in Left Shoulder
Woman With
Abdominal Pain
Man With
Abdominal Pain
Pregnant
Woman With Vaginal Pressure
Child With
Acute Neck Pain
Discussion:
Neck Spasms in Children
Woman With
Abdominal Pain
Elderly Woman
With Dizziness
Hypopyon and
Klebsiella Sepsis
Oral
HPV-Associated Papillomatosis in AIDS
Image
Diagnosis: Pott Puffy Tumor
Eyelid
Melanoma
Tachyarrhythmia
in Wolff-Parkinson-White Syndrome
A Woman with
Vaginal Bleeding and an Intrauterine Device
11. Characteristics and Outcomes of Adult Outpatients with Heart
Failure and Improved or Recovered Ejection Fraction
Kalogeropoulos
AP, et al. JAMA Cardiol. 2016 July 06 [Epub ahead of print]
Importance Heart failure (HF) guidelines recognize that
a subset of patients with HF and preserved left ventricular ejection fraction
(LVEF) previously had reduced LVEF but experienced improvement or recovery in
LVEF. However, data on these patients are limited.
Objective To investigate the characteristics and
outcomes of adult outpatients with HF and improved or recovered ejection
fraction (HFrecEF).
Design,
Setting, and Participants Retrospective
cohort study (inception period, January 1, 2012, to April 30, 2012) with 3-year
follow-up at cardiology clinics (including HF subspecialty) in an academic
institution. The dates of the analysis were May 21, 2015, to August 10, 2015.
Participants were all outpatients 18 years or older who received care for a
verified diagnosis of HF not attributed to specific cardiomyopathies or other
special causes during the inception period.
Exposures Type of HF at baseline, classified as HF with
reduced ejection fraction (HFrEF) (defined as current LVEF ≤40%), HF with
preserved ejection fraction (HFpEF) (defined as current and all previous LVEF
reports over 40%), and HF with recovered ejection fraction (HFrecEF) (defined
as current LVEF over 40% but any previously documented LVEF ≤40%).
Main Outcomes
and Measures Mortality, hospitalization
rates, and composite end points.
Results The study cohort comprised 2166 participants.
Their median age was 65 years, 41.4% (896 of 2166) were female, 48.7% (1055 of
2166) were white and 45.2% (1368 of 2166) black, and 63.2% (1368 of 2166) had
coronary artery disease. Preserved (over 40%) LVEF at inception was present in
816 of 2166 (37.7%) patients. Of these patients, 350 of 2166 (16.2%) had previously
reduced (≤40%) LVEF and were classified as having HFrecEF, whereas 466 of 2166
(21.5%) had no previous reduced LVEF and were classified as having HFpEF. The
remaining 1350 (62.3%) patients were classified as having HFrEF. After 3 years,
age and sex–adjusted mortality was 16.3% in patients with HFrEF, 13.2% in
patients with HFpEF, and 4.8% in patients with HFrecEF (P less than .001 vs
HFrEF or HFpEF). Compared with patients with HFpEF and patients with HFrEF,
patients with HFrecEF had fewer all-cause (adjusted rate ratio [RR] vs HFpEF,
0.71; 95% CI, 0.55-0.91; P = .007), cardiovascular (RR, 0.50; 95% CI,
0.35-0.71; P less than .001), and HF-related (RR, 0.48; 95% CI, 0.30-0.76;
P = .002) hospitalizations and were less likely to experience composite end
points commonly used in clinical trials (death or cardiovascular
hospitalization and death or HF hospitalization).
Conclusions
and Relevance Outpatients with HFrecEF
have a different clinical course than patients with HFpEF and HFrEF, with lower
mortality, less frequent hospitalizations, and fewer composite end points.
These patients may need to be investigated separately in outcomes studies and
clinical trials.
12. You Are Not Alone: Ten Strategies for Surviving a
Malpractice Lawsuit
Sheridan A.
Perm J 2016;20(3):16-004.
I wasn’t even
scheduled to work that morning; I had just gone into the office for a meeting.
Chatting with coworkers on my way out the door, I was told there was someone
asking for me at the reception desk. So it was there, in front of a waiting
room full of patients, that I received the papers notifying me of the lawsuit.
“Have a nice day,” the woman called out to me as she left.
Over the next
months, as the legalities played out, I struggled to keep moving. My confidence
evaporated. I’d been taught that physicians who build good relationships are
less likely to be sued, so I had obviously failed. I didn’t know how I could
face my patients—I felt like a fraud. I couldn’t sleep. I lost my appetite.
Sometimes my experience felt surreal, especially when my attorney told me:
“This case will not affect your life in any way.”
I wondered if
I would lose my job, my license, my home. Even worse, I wondered if I had lost
the trust of my colleagues.
I met a
coworker who had survived a lawsuit; she had been as stressed as I was, and
knowing that my reaction was not abnormal reassured me. I began to practice
strategies to help myself cope, and life slowly improved.
As much as we
hate to think about it, most physicians, about 60%, will be sued at some point
in their career.1 Not everyone will be as unnerved as I was, but physicians
typically do feel intense strain when faced with a lawsuit. Our trust in
ourselves and in our patients is shaken. We practice more defensively. We are
more likely to suffer depression and burnout. We may feel anxious, depressed,
angry, and afraid. Here I offer ten techniques for coping that really work…
1. Resist Isolation
Asking for
help can be tough for physicians; we’re used to being the ones people come to
for help, not the ones who need help. You will be advised not to talk with
anyone about the case, but you’ve got to know that you’re not alone.
Conversations with certain people are protected from discovery. Ask your
attorney for advice here, but typically it is acceptable to talk to family
members, counselors, and your personal physician. And you can generally feel
safe discussing your emotions while avoiding the medical details of the case.
Some
liability insurance providers cover psychological counseling costs, so make
sure to ask about this option. If you think you might benefit from talking to
someone who has had a similar experience, check to see if your organization or
insurance provider offers a peer support team.
It’s common
for physicians undergoing litigation to contemplate suicide.2 If you’re having
thoughts of suicide, pick up the phone and call someone immediately: 911, your
physician, a counselor, your spiritual advisor, or a friend or family member.
Don’t do anything until you’ve spoken with someone. Keep a list in your phone
of people you can call for support.
If you are so
depressed or anxious that you can’t stop the negative thoughts, if you’re not
eating or not sleeping, or if you feel overwhelmed, medication may be helpful.
Do not prescribe for yourself; talk to a physician you can trust. It could save
your life.
2. Use Your Strengths
We all
developed skills for managing stress as we made our way through college, medical
school, and residency. Remind yourself that you have these tools, and turn to
them now. Focus, persistence, preparation, not taking things personally—we know
how to do these things.
3. Retrain Your Brain
We all have
habitual thought patterns, places our minds go when under stress. But you can
create new patterns for yourself. Use your rational mind to respond to the
sometimes overwhelming fears that come up; this is a technique that clinicians
tend to practice a lot. When the ugly thoughts begin to spiral, and you start
thinking that you’re obviously a fraud, and no one should trust you to care for
them, stop and remind yourself of the patients you’ve helped, the procedures
that went well, and the successes you’ve had. These new neural pathways will
become more ingrained as you continue to practice them.
Research by
Martin Seligman, MD, shows that a simple gratitude exercise increases happiness
and resilience (read his book Flourish3 or go to http://ggia.berkeley.edu/practice/three-good-things).
Take a few moments each evening to consider what went well and write it down.
At first all you may be able to come up with is that you have clean sheets, or
that you had a really great piece of chocolate for dessert. But as you begin to
look for the good, you see it more, even when life seems bleak. I look forward
to this “what went well” exercise at the end of my day.
4. Take Care of Yourself
It’s
important to make room in your hectic schedule for some downtime. Staying busy
can make you feel more in control. It can distract you and keep you from
fixating on the case. But you need all your strength right now, so you’ve got
to preserve that. Sleep is crucial, to give your brain time to recover from the
stress of each day. Exercise helps release stress. Eating well fuels your body
and brain (but give yourself enough slack to turn to comfort food when you most
need it—I might not have survived without mint Newman-O’s). Take some
relaxation time, whether it’s for a massage, bedtime reading to your kids, a
hot bath, yoga, or meditation (research has shown the effectiveness of Jon
Kabat-Zinn, MD’s mindfulness-based stress-reduction program, for example). Just
be careful about using alcohol or drugs to check out—they can quickly cause
more problems than they solve when used to self-medicate.
5. Give Yourself a Break
Physicians
tend to be perfectionists, and being sued seems only to reinforce the
expectation to be perfect. Much of the time we are our own worst critics, and
we say things to ourselves that we’d never say to a colleague. Show yourself
the same compassion you’d show your child, patient, or best friend. Read
Kristin Neff, MD’s work for more information on self-compassion (http://self-compassion.org/).
For #s 6-10, see the full-text (free): http://www.thepermanentejournal.org/issues/2016/summer/6182-narrative-medicine.html
13. Can transcutaneous carbon dioxide pressure be a surrogate of
blood gas samples for spontaneously breathing emergency patients?
Nope.
Peschanski N,
et al. Emerg Med J 2016;33:325-328
Background It
is known that the arterial carbon dioxide pressure (PaCO2) is useful for
emergency physicians to assess the severity of dyspnoeic spontaneously
breathing patients. Transcutaneous carbon dioxide pressure (PtcCO2)
measurements could be a non-invasive alternative to PaCO2 measurements obtained
by blood gas samples, as suggested in previous studies. This study evaluates
the reliability of a new device in the emergency department (ED).
Methods We
prospectively included patients presenting to the ED with respiratory distress
who were breathing spontaneously or under non-invasive ventilation. We
simultaneously performed arterial blood gas measurements and measurement of
PtcCO2 using a sensor placed either on the forearm or the side of the chest and
connected to the TCM4 CombiM device. The agreement between PaCO2 and PtcCO2 was
assessed using the Bland–Altman method.
Results
Sixty-seven spontaneously breathing patients were prospectively included (mean
age 70 years, 52% men) and 64 first measurements of PtcCO2 (out of 67) were
analysed out of the 97 performed. Nineteen patients (28%) had pneumonia, 19
(28%) had acute heart failure and 19 (28%) had an exacerbation of chronic
obstructive pulmonary disease. Mean PaCO2 was 49 mm Hg (range 22–103). The mean
difference between PaCO2 and PtcCO2 was 9 mm Hg (range −47 to +54) with 95%
limits of agreement of −21.8 mm Hg and 39.7 mm Hg. Only 36.3% of the
measurement differences were within 5 mm Hg.
Conclusions
Our results show that PtcCO2 measured by the TCM4 device could not replace
PaCO2 obtained by arterial blood gas analysis.
14. Body Mass Index is a Poor Predictor of Bedside Appendix
Ultrasound Success or Accuracy
Lam HSF, et
al. West J Emerg Med. 2016;17(4):454
Objectives:
To determine whether there is a relationship between body mass index (BMI) and
success or accuracy rate of BUS for the diagnosis of appendicitis.
Methods:
Patients 4 years of age and older presenting to the emergency department with
suspected appendicitis were eligible. Enrollment was by convenience sampling.
After informed consent, BUS was performed by trained emergency physicians who
had undergone a minimum of 1-hour didactic training on the use of BUS to
diagnose appendicitis. Subject outcomes were ascertained by a combination of
medical record review and telephone follow-up.
Calculated BMI for adults and children were divided into 4 categories (underweight,
normal, overweight, obese) according to Centers for Disease Control and
Prevention classifications.
Results: A
total of 125 subjects consented for the study, and 116 of them had adequate
image data for final analysis. Seventy
(60%) of the subjects were children.
Prevalence of appendicitis was 39%.
Fifty-two (45%) of the BUS studies were diagnostic (successful). Overall
accuracy rate was 75%. Analysis by
Chi-square test or Mann Whitney U did not find any significant correlation
between BMI category and BUS success. Similarly, there was no significant
correlation between BMI category and BUS accuracy. Same conclusion was reached when children and
adults were analyzed separately, or when subjects were dichotomized into
underweight/ normal and overweight/ obese categories.
Conclusion:
BMI category alone is a poor predictor of appendix BUS success or accuracy.
Full-text
(free): http://escholarship.org/uc/item/7xs8k8xw#
15. Diagnosis and Treatment of Methanol Intoxication
Methanol
intoxication is an uncommon but serious poisoning that can cause severe
cellular dysfunction and death, and delayed treatment can increase mortality to
as high as 44%. Definitive diagnosis requires measurement with gas or liquid
chromatography, which are difficult and costly tests, and clinical
abnormalities can take 96 hours to appear, further complicating diagnosis. In
this month's AJKD, Kraut presents a case involving a 22-year-old woman with
acute methanol intoxication to investigate the value and limitations of new
diagnostic approaches and treatments.
Full-text
(free): http://www.ajkd.org/article/S0272-6386(16)30038-5/fulltext
16. Is there a role for humidified heated high-flow nasal
cannula therapy in paediatric emergency departments?
Long E, et
al. Emerg Med J. 2016;33:386-389
Background
Humidified heated high-flow nasal cannula (HFNC) therapy is a potentially
useful form of non-invasive respiratory support for children with moderate
respiratory distress and/or hypoxaemia. No prospective data support its use in
the paediatric emergency department (ED). We introduced HFNC therapy into a
paediatric ED and evaluated its use and failure rates.
Methods
Prospective observational study of all patients presenting to the Royal
Children's Hospital, Australia, who received HFNC therapy between April 2013
and September 2013 (one southern hemisphere winter season). We assessed
demographics, indications, failure rate, predictors of failure and adverse
events.
Results 71
patients commenced HFNC therapy in ED over the study period. The median age was
9 months. The most common indication was bronchiolitis (49/71; 69%). Five (7%)
of the patients failed HFNC and were escalated to other forms of respiratory
support in ED, four to nasal continuous positive airway pressure and one
required intubation. A further 21 (32%) failed HFNC therapy after intensive
care unit (ICU) admission, giving a total failure of 28 (39%). There were no
serious adverse events in ED, and one child with asthma developed air leak
syndrome after transfer to the ICU.
Conclusions
HFNC therapy may have a role in the paediatric ED as an easily administered and
well tolerated form of non-invasive respiratory support, but about one-third of
patients required escalation to a higher level of respiratory support. Further
studies should assess the safety profile of HFNC in larger series, and define
the role of HFNC in key respiratory conditions compared with other possible
interventions.
17. Spontaneous SAH: A Systematic Review and Meta-Analysis
Describing the Diagnostic Accuracy of History, Physical Exam, Imaging, and LP
with an Exploration of Test Thresholds.
Carpenter CR,
et al. Acad Emerg Med. 2016 Jun 16 [Epub ahead of print]
BACKGROUND: Spontaneous
subarachnoid hemorrhage (SAH) is a rare, but serious etiology of headache. The
diagnosis of SAH is especially challenging in alert, neurologically intact
patients, as missed or delayed diagnosis can be catastrophic.
OBJECTIVES:
The objective
was to perform a diagnostic accuracy systematic review and meta-analysis of
history, physical examination, cerebrospinal fluid (CSF) tests, computed
tomography (CT), and clinical decision rules for spontaneous SAH. A secondary
objective was to delineate probability of disease thresholds for imaging and
lumbar puncture (LP).
METHODS: PubMed,
Embase, Scopus, and research meeting abstracts were searched up to June 2015
for studies of emergency department patients with acute headache clinically
concerning for spontaneous SAH. QUADAS-2 was used to assess study quality and,
when appropriate, meta-analysis was conducted using random effects models.
Outcomes were sensitivity, specificity, and positive (LR+) and negative (LR-)
likelihood ratios. To identify test and treatment thresholds, we employed the
Pauker-Kassirer method with Bernstein test indication curves using the summary
estimates of diagnostic accuracy.
RESULTS: A
total of 5,022 publications were identified, of which 122 underwent full-text
review; 22 studies were included (average SAH prevalence = 7.5%). Diagnostic
studies differed in assessment of history and physical examination findings, CT
technology, analytical techniques used to identify xanthochromia, and criterion
standards for SAH. Study quality by QUADAS-2 was variable; however, most had a
relatively low risk of biases. A history of neck pain (LR+ = 4.1; 95%
confidence interval [CI] = 2.2 to 7.6) and neck stiffness on physical examination
(LR+ = 6.6; 95% CI = 4.0 to 11.0) were the individual findings most strongly
associated with SAH. Combinations of findings may rule out SAH, yet promising
clinical decision rules await external validation. Noncontrast cranial CT
within 6 hours of headache onset accurately ruled in (LR+ = 230; 95% CI = 6 to
8,700) and ruled out SAH (LR- = 0.01; 95% CI = 0 to 0.04); CT beyond 6 hours
had a LR- of 0.07 (95% CI = 0.01 to 0.61). CSF analyses had lower diagnostic
accuracy, whether using red blood cell (RBC) count or xanthochromia. At a
threshold RBC count of 1,000 × 106 /L, the LR+ was 5.7 (95% CI = 1.4 to 23) and
LR- was 0.21 (95% CI = 0.03 to 1.7). Using the pooled estimates of diagnostic
accuracy and testing risks and benefits, we estimate that LP only benefits
CT-negative patients when the pre-LP probability of SAH is on the order of 5%,
which corresponds to a pre-CT probability greater than 20%.
CONCLUSIONS: Less
than one in 10 headache patients concerning for SAH are ultimately diagnosed
with SAH in recent studies. While certain symptoms and signs increase or
decrease the likelihood of SAH, no single characteristic is sufficient to rule
in or rule out SAH. Within 6 hours of symptom onset, noncontrast cranial CT is
highly accurate, while a negative CT beyond 6 hours substantially reduces the
likelihood of SAH. LP appears to benefit relatively few patients within a
narrow pretest probability range. With improvements in CT technology and an
expanding body of evidence, test thresholds for LP may become more precise,
obviating the need for a post-CT LP in more acute headache patients. Existing
SAH clinical decision rules await external validation, but offer the potential
to identify subsets most likely to benefit from post-CT LP, angiography, or no
further testing.
18. Characteristics and Outcomes of Patients Presenting With
Hypertensive Urgency in the Office Setting.
Patel KK, et
al. JAMA Intern Med. 2016 Jun 13. doi: 10.1001/jamainternmed.2016.1509. [Epub
ahead of print]
Importance:
The prevalence and short-term outcomes of hypertensive urgency (systolic blood
pressure ≥180 mm Hg and/or diastolic blood pressure ≥110 mm Hg) are unknown.
Guidelines recommend achieving blood pressure control within 24 to 48 hours.
However, some patients are referred to the emergency department (ED) or
directly admitted to the hospital, and whether hospital management is
associated with better outcomes is unknown.
Objectives:
To describe the prevalence of hypertensive urgency and the characteristics and
short-term outcomes of these patients, and to determine whether referral to the
hospital is associated with better outcomes than outpatient management.
Design,
Setting, and Participants: This retrospective cohort study with propensity
matching included all patients presenting with hypertensive urgency to an
office in the Cleveland Clinic Healthcare system from January 1, 2008, to
December 31, 2013. Pregnant women and patients referred to the hospital for
symptoms or treatment of other conditions were excluded. Final follow-up was completed
on June 30, 2014, and data were assessed from October 31, 2014, to May 31,
2015.
Exposures:
Hospital vs ambulatory blood pressure management.
Main Outcomes
and Measures: Major adverse cardiovascular events (MACE) consisting of acute
coronary syndrome and stroke or transient ischemic attack, uncontrolled
hypertension (≥140/90 mm Hg), and hospital admissions.
Results: Of
2 199 019 unique patient office visits, 59 836 (4.6%) met the definition of
hypertensive urgency. After excluding 851 patients, 58 535 were included. Mean
(SD) age was 63.1 (15.4) years; 57.7% were women; and 76.0% were white. Mean
(SD) body mass index (calculated as weight in kilograms divided by height in
meters squared) was 31.1 (7.6); mean (SD) systolic blood pressure, 182.5 (16.6)
mm Hg; and mean (SD) diastolic blood pressure, 96.4 (15.8) mm Hg. In the
propensity-matched analysis, the 852 patients sent home were compared with the
426 patients referred to the hospital, with no significant difference in MACE
at 7 days (0 vs 2 [0.5%]; P = .11), 8 to 30 days (0 vs 2 [0.5%]; P = .11), or 6
months (8 [0.9%] vs 4 [0.9%]; P greater than .99). Patients sent home were more
likely to have uncontrolled hypertension at 1 month (735 of 852 [86.3%] vs 349
of 426 [81.9%]; P = .04) but not at 6 months (393 of 608 [64.6%] vs 213 of 320
[66.6%]; P = .56). Patients sent home had lower hospital admission rates at 7
days (40 [4.7%] vs 35 [8.2%]; P = .01) and at 8 to 30 days (59 [6.9%] vs 48
[11.3%]; P = .009).
Conclusions
and Relevance: Hypertensive urgency is common, but the rate of MACE in
asymptomatic patients is very low. Visits to the ED were associated with more
hospitalizations, but not improved outcomes. Most patients still had
uncontrolled hypertension 6 months later.
19. The impact of senior doctor assessment at triage on ED
performance measures: systematic review and meta-analysis of comparative
studies
Abdulwahid
MA, et al. Emerg Med J 2016;33:504-513
STUDY
QUESTION: To determine if placing a senior doctor at triage versus standard
single nurse in a hospital emergency department (ED) improves ED performance by
reviewing evidence from comparative design studies using several quality
indicators.
DESIGN:
Systematic review.
DATA SOURCES:
Cochrane Library, MEDLINE, EMBASE, CINAHL, Cochrane Effective Practice and
Organisation of Care (EPOC), Web of Science, Clinical Trials Registry website.
In addition, references from included studies and citation searches were used
to identify relevant studies.
REVIEW
METHODS: Databases were searched for comparative studies examining the role of
senior doctor triage (SDT), published from 1994 to 2014. Senior doctor was
defined as a qualified medical doctor who completed high specialty training in
emergency medicine. Articles with a primary aim to investigate the effect of
SDT on ED quality indicators such as waiting time (WT), length of stay (LOS),
left without being seen (LWBS) and left without treatment complete (LWTC) were
included. Articles examining the adverse events and cost associated with SDT
were also included. Only studies with a control group, either in a randomised
controlled trial (RCT) or in an observational study with historical controls,
were included. The systematic literature search was followed by assessment of
relevance and risk of bias in each individual study fulfilling the inclusion
criteria using the Effective Public Health Practice Project (EPHPP) bias tool.
Data extraction was based on a form designed and piloted by the authors for
dichotomous and continuous data.
DATA
SYNTHESIS: Narrative synthesis and meta-analysis of homogenous data were
performed.
RESULTS: Of
4506 articles identified, 25 relevant studies were retrieved; 12 were of the
weak pre-post study design, 9 were of moderate quality and 4 were of strong
quality. The majority of the studies revealed improvements in ED performance
measures favouring SDT. Pooled results from two Canadian RCTs showed a
significant reduction in LOS of medium acuity patients (weighted means
difference (WMD) -26.26 min, 95% CI -38.50 to -14.01). Another two RCTs
revealed a significant reduction in WT (WMD -26.17 min, 95% CI -31.68 to
-20.65). LWBS was reduced in two Canadian RCTs (risk ratio (RR)=0.79, 95% CI
0.66 to 0.94). This was echoed by the majority of pre-post study designs. SDT
did not change the occurrence of adverse events. No clear benefit of SDT in
terms of patient satisfaction or cost effectiveness could be identified.
CONCLUSIONS:
This review demonstrates that SDT can be an effective measure to enhance ED
performance, although cost versus benefit analysis is needed. The potential
high risk of bias in the evidence identified, however, mandates more robust
multicentred studies to confirm these findings.
20. Tobacco Smoking as a Risk Factor for Increased Antibiotic
Prescription.
Steinberg MB,
et al. Am J Prev Med. 2016 Jun;50(6):692-8.
INTRODUCTION:
Antibiotic resistance is rapidly spreading, affecting millions of people and
costing billions of dollars. Potential factors affecting antibiotic
prescription, such as tobacco use, could dramatically influence this public
health crisis. The study determined the magnitude of impact that tobacco use
has on antibiotic prescribing patterns.
METHODS: Pooled
data were analyzed in 2015 from the 2006-2010 National Ambulatory Medical Care
Survey, a cross-sectional survey describing use of ambulatory medical services
in the U.S. via healthcare provider-patient encounters. Patients aged over 18
years with documented tobacco use status diagnosed with an infection were
included (i.e., all encounters in the analysis included an infectious diagnosis
of interest). The analytic sample included 8,307 visits, representing 294
million visits nationally.
RESULTS: Half
(49.9%) of encounters that included any infection had an antibiotic prescribed.
Adjusted odds of receiving antibiotics among current tobacco users was 1.20
(95% CI=1.02, 1.42), and even higher for encounters of respiratory infections
(AOR=1.31, 95% CI=1.05, 1.62). Antibiotic prescription rates were lower among
patients aged over 65 years, those with comorbid asthma or cancer, non-whites,
and those covered by Medicaid and higher for primary care physicians.
CONCLUSIONS: Despite
lack of evidence-based rationale, among a national sample of patients with an
infectious diagnosis, tobacco users had 20%-30% higher odds of receiving
antibiotics than non-tobacco users. This is the first U.S. study to quantify
the magnitude of this unsubstantiated practice. Prescribers should understand
that tobacco use could be associated with higher antibiotic prescription, which
may subsequently increase antimicrobial resistance in the community.
21. Can paediatric early warning scores (PEWS) be used to guide
the need for hospital admission and predict significant illness in children
presenting to the ED? An assessment of PEWS diagnostic accuracy using
sensitivity and specificity
Lillitos PJ,
et al. Emerg Med J 2016;33:329-337
Objectives
Designed to detect early deterioration of the hospitalised child, paediatric
early warning scores (PEWS) validity in the emergency department (ED) is less validated.
We aimed to evaluate sensitivity and specificity of two commonly used PEWS
(Brighton and COAST) in predicting hospital admission and, for the first time,
significant illness.
Methods
Retrospective analysis of PEWS data for paediatric ED attendances at St Mary's
Hospital, London, UK, in November 2012. Patients with missing data were
excluded. Diagnoses were grouped: medical and surgical. To classify diagnoses
as significant, established guidelines were used and, where not available,
common agreement between three acute paediatricians.
Results 1921
patients were analysed. There were 211 admissions (11%). 1630 attendances were
medical (86%) and 273 (14%) surgical. Brighton and COAST PEWS performed
similarly. hospital admission: PEWS of ≥3 was specific (93%) but poorly
sensitive (32%). The area under the receiver operating curve (AUC) was low at
0.690. Significant illness: for medical illness, PEWS ≥3 was highly specific
(96%) but poorly sensitive (44%). The AUC was 0.754 and 0.755 for Brighton and
COAST PEWS, respectively. Both scores performed poorly for predicting
significant surgical illness (AUC 0.642). PEWS ≥3 performed well in predicting
significant respiratory illness: sensitivity 75%, specificity 91%.
Conclusions
Both Brighton and COAST PEWS scores performed similarly. A score of ≥3 has good
specificity but poor sensitivity for predicting hospital admission and
significant illness. Therefore, a high PEWS should be taken seriously but a low
score is poor at ruling out the requirement for admission or serious underlying
illness. PEWS was better at detecting significant medical illness compared with
detecting the need for admission. PEWS performed poorly in detecting
significant surgical illness. PEWS may be particularly useful in evaluating
respiratory illness in a paediatric ED.
22. Text messages on healthy habits could reduce risk of repeat
heart attacks
Australian
researchers have found that patients recovering from a heart attack who
received four text messages per week asking about their health and giving
health suggestions were more likely to have slower heart rates, lower
cholesterol levels and less body fat and maintain lower blood pressure than the
control group. The findings, based on 700 coronary heart disease patients, also
showed that those who received text messages had smaller waist sizes and were
more likely to be active and quit smoking than the control group.
WSJ: http://www.wsj.com/articles/how-to-prevent-a-heart-attack-text-patients-on-healthy-habits-1466992860
Study full-text
(free): http://jama.jamanetwork.com/article.aspx?articleid=2442937
23. Micro Bits
A. The CMS Sepsis Mandate: Right Disease,
Wrong Measure
Michael Klompas, MD, MPH; and
Chanu Rhee, MD, MPH
In 2015, the Centers for Medicare
& Medicaid Services began requiring hospitals to report their adherence to
treatment bundles for patients with sepsis. The reporting rules are rigid and
onerous and may not always reflect best clinical care for all patients. The
authors of this article describe what they think might be done about the
situation…
B. Psychological factors contribute to
delayed symptom resolution after concussion
Although postconcussive symptoms
for most children resolve in one to two weeks, 15% to 30% of children with a
concussion experience symptoms that last at least three months. Psychological
components such as pre-existing anxiety and depression influence symptomatology
after concussion. In this study, noninjury factors, especially somatization and
anxiety, contributed significantly to delayed symptom resolution. Primary care
providers should consider referring patients with persistent symptoms to
providers with expertise in pediatric behavioral health.
C. Researchers find Tdap vaccine is safe in
pregnant women
A study in Human Vaccines &
Immunotherapeutics found that Tdap vaccine is safe for pregnant women and can
help protect their newborns from whooping cough in the short term. The
findings, based on data involving nearly 1,800 births to women who received and
did not receive the shot, showed the only difference in health outcomes was in
cesarean-section rates, which researchers said was not likely tied to the
vaccine.
D. How to Nap
Malia Wollan. New York Times.
June 19, 2016
“Duration is very important,”
says Damien Léger, a doctor who runs the sleep-research center at the
Hôtel-Dieu hospital in Paris. Aim to sleep for 20 minutes. Anything longer, and
you risk drifting into what scientists call slow-wave sleep, a state of languid
brain-wave activity considered important for consolidating memories. Set an
alarm clock. A slow-wave encounter is likely to leave you with what Léger calls
“sleep drunkenness” instead of a feeling of rejuvenation…
E. Serum S100B as a Surrogate Biomarker in
the Diagnoses of Burnout and Depression in Emergency Medicine Residents
Conclusion: S100B levels
correlate with depression scores and emotional exhaustion in burnout syndrome.
The findings suggest that S100B can be used as a marker to screen emergency
medicine residents and detect individuals with high risk for depression and
burnout syndrome.
F. Diastolic Hypotension, Troponin Elevation,
and Electrocardiographic Changes Associated With the Management of Moderate to
Severe Asthma in Children
Conclusion: In a subset of
children with moderate to severe asthma, diastolic hypotension, troponin
elevation, and ECG ST-segment change occur during administration of continuous
albuterol. Future studies are necessary to determine the clinical significance
of these findings.
G. Ticagrelor no better than Aspirin in Acute
Stroke or Transient Ischemic Attack
H. Attitudes and Practices of Euthanasia and
Physician-Assisted Suicide in the United States, Canada, and Europe
Conclusions and Relevance: Euthanasia and physician-assisted suicide are
increasingly being legalized, remain relatively rare, and primarily involve
patients with cancer. Existing data do not indicate widespread abuse of these
practices.
I. Intensive Beats Standard Blood Pressure
Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years
Conclusion: Among ambulatory
adults aged 75 years or older, treating to an SBP target of less than 120 mm Hg
compared with an SBP target of less than 140 mm Hg resulted in significantly
lower rates of fatal and nonfatal major cardiovascular events and death from
any cause.
JAMA article: http://jama.jamanetwork.com/article.aspx?articleid=2524266
JAMA editorial excerpt: “Because of the trial exclusion criteria, the current results may not be applicable to individuals with diabetes, heart failure, prior stroke, or postural decreases in BP. Also, despite the impressive benefits observed in the intensive group that had an SBP target of less than 120 mm Hg, the mean SBP actually achieved in this group was 123 mm Hg, indicating that not all patients in the study attained the preset SBP goal of less than 120 mm Hg. Furthermore, only ambulatory, community-based persons were recruited into the study, so the results may not be relevant to frail individuals and others restricted to their homes or to institutions…
JAMA article: http://jama.jamanetwork.com/article.aspx?articleid=2524266
JAMA editorial excerpt: “Because of the trial exclusion criteria, the current results may not be applicable to individuals with diabetes, heart failure, prior stroke, or postural decreases in BP. Also, despite the impressive benefits observed in the intensive group that had an SBP target of less than 120 mm Hg, the mean SBP actually achieved in this group was 123 mm Hg, indicating that not all patients in the study attained the preset SBP goal of less than 120 mm Hg. Furthermore, only ambulatory, community-based persons were recruited into the study, so the results may not be relevant to frail individuals and others restricted to their homes or to institutions…
“What should clinicians now
recommend for the management of hypertension in most patients 75 years or
older? Although the story is incomplete, the available evidence supports a
stepwise approach to treatment beginning with an initial SBP goal of less than
140 mm Hg. If lowering SBP to that level is tolerated well, further titration
with careful monitoring should be considered to achieve an SBP goal of less
than 130 mm Hg. The choice of antihypertensive medications can vary depending
on clinician and patient preference, considering that several studies have
shown that the major benefit of treatment depends on BP lowering rather than
type of antihypertensive medication used.11 In general, however, the preferred
first-line drugs should be diuretics, calcium antagonists, angiotensin receptor
antagonists, and angiotensin-converting enzyme inhibitors. β Receptor
antagonists are also valuable as first-line agents in patients with coronary
heart disease, arrhythmias, and heart failure. Combination drug preparations
are useful because therapy often will involve multiple drugs. Since older
persons with SBP less than 110 mm Hg while standing were excluded in SPRINT,
the risk of syncope and falls may have been underestimated, and particular
attention should be given to avoidance of orthostatic hypotension with
treatment…”
J. Brain Training Does Not Improve Academic
Outcomes in Kids
Conclusion: On balance, we cannot
recommend this intervention as a population-level selective prevention strategy.
JAMA Pediatr article: http://archpedi.jamanetwork.com/article.aspx?articleid=2498559
K. Effect of Pictorial Cigarette Pack
Warnings on Changes in Smoking Behavior: A Randomized Clinical Trial
Conclusion: Pictorial warnings
effectively increased intentions to quit, forgoing cigarettes, quit attempts,
and successfully quitting smoking over 4 weeks. Our trial findings suggest that
implementing pictorial warnings on cigarette packs in the United States would
discourage smoking.
L. Aspirin Use for the Primary Prevention of
Cardiovascular Disease and Colorectal Cancer: U.S. Preventive Services Task
Force Recommendation Statement
Recommendations: The USPSTF
recommends initiating low-dose aspirin use for the primary prevention of CVD
and CRC in adults aged 50 to 59 years who have a 10% or greater 10-year CVD
risk, are not at increased risk for bleeding, have a life expectancy of at
least 10 years, and are willing to take low-dose aspirin daily for at least 10
years. (B recommendation)The decision to initiate low-dose aspirin use for the
primary prevention of CVD and CRC in adults aged 60 to 69 years who have a 10%
or greater 10-year CVD risk should be an individual one. Persons who are not at
increased risk for bleeding, have a life expectancy of at least 10 years, and
are willing to take low-dose aspirin daily for at least 10 years are more
likely to benefit. Persons who place a higher value on the potential benefits
than the potential harms may choose to initiate low-dose aspirin. (C
recommendation)The current evidence is insufficient to assess the balance of
benefits and harms of initiating aspirin use for the primary prevention of CVD
and CRC in adults younger than 50 years. (I statement)The current evidence is
insufficient to assess the balance of benefits and harms of initiating aspirin
use for the primary prevention of CVD and CRC in adults aged 70 years or older.
(I statement)
Baseline CVD Risk
The magnitude of the
cardiovascular risk reduction with aspirin use depends on an individual's
initial risk for CVD events. Risk assessment for CVD should include
ascertainment of the following risk factors: age, sex, race/ethnicity, total
cholesterol level, high-density lipoprotein cholesterol level, systolic blood
pressure, hypertension treatment, diabetes, and smoking. An online version of
the ACC/AHA risk calculator can be found at http://tools.acc.org/ASCVD-Risk-Estimator
M. Contrast CT Scans in the ED Do Not
Increase Risk of Adverse Renal Outcomes.
Really?
Heller M, et al. West J Emerg
Med. 2016;17(4):404
Full-text: http://escholarship.org/uc/item/9wz8j32t
N. Giving Your Cell Phone
Number to Patients
Verner CF.
West J Emerg Med. 2016;17(4):477.
