Monday, May 9, 2011

Vital Sign "Triggers"

So, this was an interesting article about a system of vital sign "triggers" an ED implemented to get nurses to flag specific patients for more urgent attention.  Not unexpectedly, the study finds that, when nurses get physician's attention, everything happens more rapidly to those patients, orders, antibiotics, and disposition.  The problem is, the article doesn't address the appropriateness or any unintended consequences of this sort of intervention.  The theory would be that these abnormal vital signs represent patients that need more urgent evaluation, but vital signs are always just one piece of the puzzle.  In any event, this study spotlights something that can be reasonably construed as important - nurses should be educated to recognize potentially ill patients and notify physicians.

Of course, in the back of my mind, I was envisioning our ED (and likely many around it) which rooms patients first, and then triages them - and it then becomes the responsibility of the nurse whose zone they have entered to take and record vital signs.  This results in patients being roomed much faster - which many studies have shown is likely a good thing.  Unfortunately, when a patient is roomed to the high-acuity side based on chief complaint, the nurse to which they are assigned may be quite busy with their other high-acuity patients...and that patient may just sit in the room for some time without an assessment or vital signs.

Everything has potential unintended consequences.

Sunday, May 8, 2011

...and Here is Why the Elderly Are Falling

Orthostatic intolerance.

Not much more to say.

An entire quarter of their convenience sample of elderly (mostly female) volunteers had a 60 point drop in their blood pressure upon standing, with only a modicum of recovery within 2 minutes.

Antihypertensive polypharmacy was weakly associated with orthostatic intolerance, and the presence of orthostatic intolerance was weakly associated with an increased number of falls.

So, if the disease (hypertension) doesn't harm you, the treatment will.

Saturday, May 7, 2011

2005 AHA CPR Guideline Changes Had No Effect

Most recently, the new "hands-only" CPR guidelines have received a lot of press and attention, and there's a lot of excellent research showing that any intervention that stops CPR decreases survival.  Well, the last time they revised the CPR guidelines, they were also intended to decrease CPR pauses, including changing the manner in which defibrillation was performed, making longer CPR intervals, and eliminating pulse checks after shocks.

The "Resuscitations Outcomes Consortium" did a crossover study looking at survival to hospital discharge before and after the implementation of the new guidelines...and they found no statistically significant differences.  They did find a clinically significant improvement in VT/VF survival that went from 14% to 18%, but the p-value was 0.06 - and it's hard to attribute that solely to the guidelines because there are other significant baseline differences, particularly a 28% to 34% increase in bystander CPR.

Should be interesting to see if widespread implementation of the new CPR guidelines increase overall or subgroup survival.

The paper also mentions their current studies, looking at whether automated devices improve outcomes and when AED analysis should be performed in sequence.

Thursday, May 5, 2011

Early Recognition of Massive Transfusion

From trauma resuscitation, a Chinese study trying to predict who will need massive transfusion after trauma.  They have a 7-item scoring system retrospectively derived...and it's probably not terribly helpful.

It's a nice idea, considering there's only so much blood readily available in the bank, and a lot of massive transfusion protocols are 1:1 with FFP and sometimes platelets, so advance warning based on the initial clinical evaluation would definitely be helpful.  There are some interesting pieces of information in the paper, although, I wish they had all their OR listed for massive transfusion, as opposed to just the ones that shook out from their stepwise regression.  Their highest predictor for massive transfusion - a hemoglobin < 7 g/dL with an OR 45.7.  SBP < 90 and positive CT or FAST were also predictors with useful OR.  Their rule is a little unusual for a theoretically beneficial intervention (massive transfusion), as they focus on specificity rather than sensitivity - probably due to a need to conserve blood component products.

In the end, though, I think most folks with a hypotensive trauma patient whose FAST is positive and a Hgb < 7 could clinically predict massive transfusion as well as this rule does.

Wednesday, May 4, 2011

Pediatric Sedation with Propofol

Lovely descriptive statistics of 25,000 occurrences of propofol sedation in children.

Interestingly - 75% of their sedations occurred in radiology.  My experience has primarily been to sedate children for uncomfortable procedures - but I am aware that our pediatric critical care intensivists staff the MRI machine specifically to run sedations for children for imaging.

2.3% had "serious adverse events" - although their "other adverse events" includes 1.3% who had "unexpected need for PPV", which, to me, seems rather serious.  1% had airway obstruction, another 1% had desaturation and 0.5% had apnea.  They also did some chart mining to see if anything showed up as associated with a serious adverse event.  The highest OR was only 4.6, and that was when an "upper respiratory" diagnosis was documented in the chart.  Other associations included prematurity, and then the addition of benzo, ketamine, anticholinergics, or opioids to the sedation.

I would say there are a couple emerging trends that might help further increase sedation safety - addition of end-tidal CO2 monitoring might give better warning of apnea and desaturation, and increased use of nitrous oxide may reduce the number of propofol sedations needed.  Otherwise - be ready for too much excitement in one out of fifty pediatric sedations.

Tuesday, May 3, 2011

MRSA is Everywhere and You Can't Stop It

No doubt your hospital has an infection control committee, signs for handwashing, sterile showers, plasma arc denudes, etc. and your e-mail box is filled with Journey to Zero or Destination: Excellence spam.

Unfortunately, it didn't seem to work up at Mayo.  They had ICUs where they put signs up trying to inspire more barrier precautions and hand hygiene, they did more surveillance and topical intranasal antibiotics - and the intervention group valiantly tried to obey.  They were somewhat poor in their compliance with suggested barrier precautions, but they were used far more often than in the control clusters - and they found no differences in any of their measures of MRSA or VRE colonization or infection following their intervention.

I will certainly not argue against cleanliness and godliness, but I am impressed they published this lovely negative study to confound us and make us think about how we should go about focusing our resources effectively.

Monday, May 2, 2011

News Flash: Dilaudid Treats Pain

Albert Einstein in Montefiore is singlehandedly, repeatedly pushing literature regarding appropriate titration of pain control in the Emergency Department.  They have several previously published papers describing their hydromorphone 1 + 1 protocol, describing its safety and efficacy.  This paper is their prospective, randomized version demonstrating its safety and superiority to "usual practice".  You could implement their protocol tomorrow and have better narcotic pain control in your ED.  It clearly works.

But the real issue this line of research uncovers is not that they've discovered a magic protocol.  What we're missing by taking the simple interpretation is more that our pain control in the ED is flawed.  If you look at the morphine equivalents their patients received in this article, they're preposterous.  I am a huge proponent of 0.1mg/kg for morphine - even in adults - and their mean dose in the "usual care" arm was 6mg morphine equivalents, and their mean additional dose was 3mg.  0.1mg/kg is a starting dose for morphine that gives less than 50% of patients adequate pain relief - which is where the second part of their protocol comes in.  Scheduled reassessment for pain and a standing order for additional medication is another area where "usual care" will obviously fall behind, simply because of the uncontrollable chaos of the ED.

So, my take home from this article is that protocolized, standing orders for narcotic analgesia in appropriately selected patients is safe and effective, and, you can use their protocol or develop your own.

Sunday, May 1, 2011

Ardbeg Supernova

Sunday Scotchday.

This is a rather special scotch I bought a friend as a gift.  It comes from an Islay distillery with a reputation for strong notes of peat, and this bottling is "the peatiest", hence, the special Supernova designation.  They've even gone so far as to scientifically prove the peatiness by measuring a phenol level.

What's surprising about this Scotch is how smooth it is.  Obviously, at 60% alcohol by volume, it's a harsh beverage until you dilute out the paint thinner quality - but once you do that, you it is truly a unique drinking experience in how it truly builds and explodes on your palate in a very pleasant, prolonged finish. Good luck finding this in a local store - I had to order it off the internet from a distributor who did ship to the U.S.

Saturday, April 30, 2011

Badgering Your Consultants to Death

This article describes a fascinating and absolutely untenable situation with numbers that just defy comprehension.

At an academic teaching hospital in Korea, 75% required consultation towards their admission rate of 36% - and their ED LOS median was seven hours.  Then, they implemented this brutal system in which an automated computer protocol paged out a consultation - and then, at the three hour mark - if there was still no disposition, they autopaged every resident in the consulted department.  Then, at the six hour mark, a page went out to every resident and faculty member in the consulted department regarding the disposition delay.  And their median ED LOS and time to disposition basically each improved by an hour and a half with this intervention.

So, this situation is insane.  Their admission rate is pretty high, but I still cannot fathom consulting on 75% of my patients.  And, these time to disposition numbers are equally alien, especially to a community emergency physician.  At my hospital, if a consultation goes over one hour in our EDIS, the badgering begins - but it's more likely friendly, desperate begging as opposed to this hospital's automated irritant spam.

So, shed a tear for Korea and their dysfunctional ED.

Friday, April 29, 2011

Intracranial Extension of Sinusitis in Children

Interesting descriptive study of a decade's worth of children transferred/admitted to Texas Children's in Houston with intra-orbital or intra-cranial extension of their sinusitis.  It's really just a summary of the clinical and hospital courses of 118 patients identified through retrospective chart review.

Interesting tidbits:
- Of these patients, 40% had been prescribed outpatient courses of antibiotics prior to the time of diagnosis of intra-cranial or intra-orbital extension.
- All patients with intra-orbital involvement presented with eye swelling.
- Intra-cranial extension had substantially (and significantly) more headache and vomiting, and only 67% received antibiotics prior to transfer.
- Identical numbers in each group - 16% - of patients were afebrile upon presentation.
- 33% of patients with intracranial extension of sinusitis did not complain of a URI-like syndrome at presentation.
- Frontal sinus involvement was associated with 84% of their intra-cranial extension.
- All organisms recovered were sensitive to clindamycin or vancomycin plus cefotaxime except for a single pseudomonal infection.
- There were no deaths, and four patients had persistent neurologic or visual sequelae.

Short summary - orbital cellulitis was a little more straightforward in diagnosis than intracranial extension of sinusitis, and a significant minority of both groups would definitely diagnostic challenges.  CT imaging, anathema as it may be, is the diagnostic modality of choice.

Thursday, April 28, 2011

Psychiatry & ED Agreement

Not as helpful an article as I hoped when I pulled it to peruse.  Part of the issue is the surveys are administered to psychiatry and emergency department residents regarding their evaluation of the patient, so you're almost certain to have a lot more variability - not just in assessment, but in level of understanding of language and the process of acute psychiatric assessment.

Where I'm not surprised we have a low kappa with our psych colleagues are areas like mood disorders - as emergency physicians are looking more at threat to themselves, threat to others, acute psychosis, and other factors affecting their global level of function to determine whether they are safe for discharge.  What's interesting are the 2x2 tables regarding things like suicidality, where psychiatry is eliciting suicidality in a significant number of individuals where that was not reported by the emergency physician.  Out in community practice where psychiatry is not always readily available, the discharge of psychiatry patients is a high-risk endeavor - and I would have expected the emergency physician to be more attuned to suicide risk and document a lot more concern for suicidality that was deemed not an issue for the consulting team.

Mostly just an article to read out of passing curiosity that won't impact your practice.

Wednesday, April 27, 2011

More Conflicts of Interest

I don't know if I'm the only one who gets depressed by these sorts of articles.  You have the progression through medical school and residency, you finally start feeling up-to-date on current treatment, your Grand Rounds invited speakers present results from some trials, and you think you're fully armed to provide the best care modern medicine can provide.

And, then you discover that it's all a stack of cards predicated on results influenced by pharmaceutical funding.

This article is from JAMA, again, very important topic given studies performed with pharmaceutical funding have a fourfold greater chance of reporting positive results.  They looked at meta-analysis, one of the techniques we try to use to increase statistical power in our reading of the literature.  They discovered that nearly no meta-analyses included comment on whether the included studies were funded by pharmaceutical literature - even though 60% of the studies reported funding sources, and 70% of those studies reported receiving funding from the pharmaceutical industry - and the same sort of dismal reporting for author conflicts of interest.  What it means - it's another cautionary tale regarding how pervasive the masking of conflicts of interest really is, and how easily it creeps into the medical literature without our knowledge.

Tuesday, April 26, 2011

Adrenal Insufficiency in Pediatric Shock

This falls into the "don't use etomidate" pile of literature.  Well-demonstrated, primarily in the pediatric literature, that etomidate and its association with adrenal insufficiency results in poorer outcomes in shock.  This article doesn't look at etomidate, but rather it describes relative or absolute adrenal insufficiency in pediatric shock, and finds it relatively pervasive.  It then finds an association between their two definitions of adrenal insufficiency and length of stay, length of ventilator days, and required doses of vasopressors.  They only 5% mortality in their study, so they can't comment on any mortality association.

So, this is another study that helps describe why etomidate may be contributing to poorer outcomes.  The days of ketamine + rocuronium RSI are coming (we'll save the succinylcholine vs rocuronium debate for another day).

Monday, April 25, 2011

Out of Hospital Arrest Score Validation

There are nice studies in the U.S. defining and validating a rule that determines which patients are unlikely to have ROSC or survival to hospital discharge, e.g. BLS-TOR.  This is a study from France that looks at people who do have ROSC to see, not just if they'll survive, but survival where the patient is not severely disabled or vegetative.  One of the nice things about Europe is that their cultural perception of "life" really has to do more with living, and not just simply "being alive".  So, whether we can actually implement something like this in the U.S. may be difficult.

It's a chart review, which limits its quality to some extent.  The other real issue I have with this OHCA score is its complexity - it incorporates initial rhythm, no-flow and low-flow intervals, and admission levels of creatinine and lactate.  The U.S. validation cohort had 34% therapeutic hypothermia, which is pretty good - the derivation cohort was only at 11%.  Predictors of good neurologic outcome, consistent with other articles: ventricular fibrillation, bystander CPR, lower creatinine and lactate.

Unfortunately, for this rule to get up to 100% specificity, the sensitivity drops to 19%.  Alternatively, you could say that's 20% of out-of-hospital arrest ROSC that shouldn't have further intervention, which would be an important cost and medical resource utilization savings.

So, this is something that your colleagues in critical care are going to use to discuss prognosis, although I'd like to see something along these lines that helps attenuate the number of people we resuscitate until our post-resuscitation care demonstrates much, much improved outcomes.

Sunday, April 24, 2011

"Teachable Moments"

From the critical care literature, looking at whether the ICU admission represents a "teachable moment" for counseling against health-endangering behaviors.  It's a review article asking the question whether interventions at the time of admission to an ICU - i.e., a close brush with death - are effective.

This is relevant to the Emergency Department for those situations where you want to shake your patients and tell them "you did this to yourself, you fool!"

They look at the literature for nicotine cessation and for alcohol cessation.  The nicotine cessation literature is rather bleak.  They break down the interventions to <15 minutes vs. >15 minutes, and then whether contact after hospital discharge is helpful.  Pretty much, unless you have a mechanism for prolonged after-discharge contact and counseling, you won't get any meaningful results.

As far as alcohol goes - there are good studies that support questionnaires, lab work, or scoring systems to identify individuals at risk for alcohol-related injuries or illness.  However, all the studies in their review show regardless of behavioral intervention, no decrease in alcohol consumption at discharge is seen.

So, sadly, almost assuredly, the ED, with the minimal time and follow-up available to us, is unlikely to be a place where impactful counseling is feasible.

Saturday, April 23, 2011

Ultrasound Guided Subclavian Access

Ultrasound guidance and visualization of anatomy and/or the needle tip during jugular venous cannulation is, essentially, the standard of care given the frequency of complications using anatomic landmarks alone - not to mention the "growing" U.S. population that has outgrown their landmarks.  It's also the standard of care because residents finishing their training right now have never done an IJ without the ultrasound.

So, what do we do when we don't have ultrasound?  Then you're left with the decision to do subclavian or femoral.

Well, ultrasound-guided subclavians are well-described in the literature, and this is an article from our critical care colleagues with 400 subclavian access attempts - half with landmarks and half with ultrasound. Fewer complications, fewer attempts, less time to access.  Hard to argue with that.  If you aren't getting familiar with ultrasound, I would start thinking about ways to become more comfortable.

Friday, April 22, 2011

Fluoroquinolone-Resistant E. Coli

Doom and gloom from the Netherlands regarding antibiotic resistance in E. coli.  Although they focus on the resistance rates to fluoroquinolones, the more interesting take-home point from this article is the risk factors described for polypharmacy resistance.

Depending on your local resistance patterns, 88% susceptibility to E. coli for fluoroquinolones either sounds great or it sounds terrible.  What's interesting is that the strains of E. coli in this study that had fluoroquinolone resistance also had 33% resistance to amoxicillin-clavulanate, 65% resistance to TMP-SMX, and 14% had an ESBL gene.  So, you can really extend their findings to more a listing of predictive factors for resistance to multiple antibiotics.  In there study, the main univariate risk factors were indwelling catheter (OR 6.0) and prior fluoroquinolone use within six months (OR 18.6).  Less prominent, but still statistically significant were underlying urinary tract disorder (OR 2.3), recurrent UTI (OR 2.2), or recent hospitalization (OR 2.3).

Their conclusion that the presence of any of these risk factors should result in a urine culture being sent, which is reasonable - although even in the absence of risk factors, there was still an 8.2% chance of fluoroquinolone resistance.

Thursday, April 21, 2011

Norepinephrine is Superior to Dopamine

Last day of Journal Club for April.

It is very interesting how generational medical practice is - currently training physicians are accustomed to using norepinephrine for virtually everything as the vasopressor of choice (except, well, when there's a medication shortage like this past month), while previous generations have a comfort zone with dopamine.

This is a very nice study in a lot of ways and it does a good job if illustrating that dopamine and norepinephrine have very small but relevant clinical effects.  Some of their inclusion criteria are a little odd - hypoperfusion/decreased CVP after only 1000mL of crystalloid or 500mL of colloid?  And 246 of their patients suffered from hypovolemia due to acute hemorrhage - so you can really question why anyone was reaching for a pressor instead of a Cordis or the OR - and, there are a few other instances with small numbers where neither dopamine or norepinephrine is your vasopressor of choice (e.g., anaphylactoid shock, spinal shock).

But, they had good randomization and their treatment groups are very similar.  And what did they find?  No difference.

Well, not completely true - no difference in ICU mortality with a p = 0.07 in favor of norepinephrine and no difference in in-hospital mortality with a p = 0.24 favoring norepinephrine.  So, norepinephrine is favored, but statistically the results are not bulletproof.  I think the trends are reasonable, but it's certainly worth keeping an open mind.  Alternatively, if you wanted to never use dopamine again, you can definitely argue that norepinephrine is no worse.

Secondary outcomes generally trend in favor for norepinephrine with a few reaching significance - although, when you look at 20 secondary outcomes, you're bound to find some significant differences.  The most important difference is the incidence or arrhythmias, primarily atrial fibrillation, which occurred in 24% of the dopamine group and 12.4% of the norepinephrine group at a p = <0.001.

It's an important paper to have around to be on the same page as the critical care colleagues.

Wednesday, April 20, 2011

Famoditine in Urticaria

Dredged up for Journal Club from The Year 2000 (that was the future, once).

You might scoff at this article because it enrolls a grand total of 25 participants with acute urticaria, ten of which receive diphenhydramine and fifteen receive famotidine.  You might be more impressed to know that this is pretty reflective of the evidence we have regarding H2-blockers in the treatment of urticaria.  Another study from 1993 compares diphenhydramine, famotidine, and cromolyn sodium - and only enrolls 20!

It is mildly amusing to see them report there is no significant difference between the groups when they don't have the power to detect any.  Regardless, our H2 blockers provide some relief, it's likely additive, and they're inexpensive and safe.

The "definitive" study at present supporting our H1 + H2 blocker for acute urticaria or allergic reaction in the emergency department enrolls 91, and it shows diphenhydramine + cimetidine is superior to diphenhydramine alone.

Tuesday, April 19, 2011

Antibiotics Are Unnecessary After MRSA Abscess Drainage

Almost a year old now, but it's been dredged up for Journal Club (spoiler alert: the next two days might have something in common with vis-a-vis dredging).

Small study randomizing skin abscess to placebo vs. TMP-SMX after incision and drainage in children.  I think it's a fair article with decent external validity, as I would say this directly addresses the practice pattern of pediatric emergency physicians, let alone community pediatricians.  The real issue is statistical power for their secondary endpoint and some minor differences between their two groups.  Treatment failures comparing placebo and TMP-SMX are identical - which just goes to show you that the I&D really is the most important element of treating abscesses.  They do a lot of packing!  I suppose I'm almost more surprised there isn't more packing, since that's the commonly accepted practice, but I digress.

The only fire remaining in their argument is that antibiotics will decrease recurrent abscesses.  And, I am willing to give them that - although, I really expect, if they had a longer follow-up period, a lot of those abscesses would return after the antibiotics were stopped because the environment requires eradication.  However, there's a significant difference in the number of each group with a history of recurrent abscesses favoring the TMP-SMX group, which might explain the magnitude of their difference in recurrent lesions within 10 days.

Too small a study to change our practice - although, our practice probably should never have changed from not treating abscesses with antibiotics in the first place.

Monday, April 18, 2011

Oxy-Free ED

A little bit of a follow-up to yesterday's post on adverse events - and because it was mentioned on EM:RAP a couple months ago.

This is the group up in Washington state that is trying to cut down on the number of narcotics being diverted from their Emergency Department into the community.  It's a nice discussion and something that if you're not already doing something about it, you're not doing enough.  A unified strategy across their entire department helps keep patients and physicians on the same page and standardizes their treatment.  I know at a small critical access hospital at which I work, some patients will call ahead to see which physician is working - since they know they won't be getting their usual fix with certain docs.

Sunday, April 17, 2011

Everything is a Poison...

...when taken in inappropriate amounts.

The NYT reports on a recent AHRQ release that doesn't tell us a lot that's new - more hospital and ED visits are coded with medication side effects - a "50% increase since 2004".  The problem with the lay article is that it focuses on these issues as "medication errors" as some alarming decline in quality in U.S. healthcare.  Part of the problem with this release is that it's simply data - it's not a study or a statistical analysis that attempts to control for other confounding influences - have the number of prescriptions for each of these classes gone up?  What's the average age of these patients presenting with errors (i.e., aging boomers)?  There are a lot of other factors contributing to whether a medication results in an adverse effect, and they aren't just "errors".  The ED data isn't all that insightful, although it is interesting to see how it differs from the inpatient errors.  The #1 culprit for the ED is "Other", which is 261k compared to 118k opiate adverse events - which basically invalidates their data when most of your data points fall into an unknown category.

Saturday, April 16, 2011

Heparin-Binding Protein for Bacterial Meningitis

This study came out highlighted by the last Emergency Medicine Journal Watch.

Now, I don't want to steal Emergency Medical Abstracts thunder, since I'm sure they're going to tear this article to shreds in a few months, but let me just comment on the conclusion of the Journal Watch reviewer that this is a "promising new biomarker that...might play the same role in bacterial meningitis that D-dimer does in venous thromboembolic disease" and that "an HBP level >20 ng/mL should prompt empirical therapy for bacterial meningitis" like this assay is something we should incorporate into our practice.

Part of the problem with this study is their methodology.  They used HBP to diagnose bacterial patients where they could diagnose bacterial meningitis.  Which means, these are all patients in which they already were able to make the diagnosis of bacterial meningitis without this magical new test.  So, immediately from that standpoint, it doesn't add any value.

They also used two different samples, including, apparently, some they had on file from a decade ago - but their justification seems reasonable.

They compare the sensitivity and specificity of their test to the sensitivity and specificity of CSF polynuclear cells and CSF WBC count - and they're statistically identical.  And, specifically, they are marginally better in absolute terms and likely in AUC vs. any of those tests individually, but when taken against the combined information given by all the CSF tests we already send off, there is likely no clinical difference.

Lastly, the most important words are on the first page: "Hansa Medical AB has filed a patent application on the use of HBP as a diagnostic tool in meningitis.  Dr. Linder, Dr. Christensson, Dr. Björck, and Dr. Åkesson are listed as inventors."

My conclusion: this is an unnecessary test to add to your arsenal.  Read the article, make your own conclusion.

Friday, April 15, 2011


I went to a Scotch tasting event the other day hosted by Glenmorangie - which is, supposedly, the top-selling Highland single-malt - and while the event itself was rather bland, their line of double-barreled scotches are worth mention.  Essentially, they take their regular 10-year Highland single-malt, and then they spent two more years aging it in barrels from Port, Sherry, or Sauternes.  They are all worth trying and tasting, simply because they really have a lot of interesting flavor, and mostly sweetness, onto the base Highland.  The Nectar D'Or - really for no reason - has a $20 markup over the other double-barreled variants LaSanta and Quinta Ruban, and, while quite good, is kind of a lot of markup when you consider the competition in that $40 to $60 dollar range.

And, more importantly, they have them in the state-run liquor stores out here in rural areas where I currently live.  When I do feel like purchasing one, I tend to go for the LaSanta.

Addendum:  Hiding a FFBall team logo secretly on the inter webs.

Dexamethasone in Asthma

Steroids are part of the mainstay of therapy for acute exacerbations of reactive airway disease - but does it matter which steroid we use?

I think it's clear that answer is: "no".  Multiple studies support using dexamethasone rather than prednisone - best described in pediatrics, but this study reaffirms its utility in adults.  The advantage is its half-life of 72 hours, meaning it requires fewer doses and, in theory, greater compliance.  Although, really, this study is limited directly as a pharmacologic comparison study specifically because of the compliance issue - there's no guarantee every patient finished their course of prednisone, while it's pretty likely patients managed to take at least the 2nd non-placebo dose of their dexamethasone.  However, in terms of clinical relevance - it reflects the compliance issues encountered in reality.

There's an underpowered single-dose dexamethasone pediatric study out there, as well, which appears promising.  I like the idea of 100% compliance guaranteed by a single-dose in the ED, but it's something that needs more data.

Thursday, April 14, 2011

Emergency Response Teams

This is an idea that sounds great in theory - if you have a roving team of skilled resuscitation professionals in your hospital assisting nurses who are concerned about their patients, you can intervene on these patients before they deteriorate, keep people from escalating into the ICU, and improve outcomes.  It's such a great idea that the entire country of Australia has been spurred into implementing these.  My hospital has them, and, no doubt, many other hospitals do as well.

The problem is, they're having a hard time demonstrating their efficacy.

A study out of Stanford last year reported that, at their VA hospital, implementation of emergency response teams (ERTs) reduced mortality.  Unfortunately, on closer reading, ERTs reduced mortality on the floor, and their primary intervention was to move people to the ICU - where their mortality was no longer counted in the study.  While it is rather graceless to have people coding and dying on the floor, unfortunately they did not show the outcomes they claimed.

This more recent report, from Australia, as mentioned above, is a before and after analysis of hospital-wide mortality, CPR rates, etc. with their ERTs.  They likewise show benefits, with ICU admissions, CPR rates, and mortality all declining after implementation.  However - and they very astutely point this out themselves - one of the most significant functions of the ERTs was to clarify code status and affirm a greater number of people as DNR or futile resuscitation.  While this function, if it reduces ICU admissions, is absolutely a cost and resource savings, I don't think it's precisely how they wanted to justify implementation of ERTs.

There are many reasons to have ERTs, but a mortality and cost-benefit justification has not yet been well-demonstrated.

Wednesday, April 13, 2011

News Flash - Better Electronic Medical Records Are Better

In this article, providers are asked to complete a simulated task in their standard EMR - which is Mayo's LastWord supplemented by Chart+ - vs a "novel" EMR redesigned specifically for a critical care environment with reduced cognitive load and increased visibility for frequently utilized elements and data.  In their bleeding patient scenario, their novel EMR was faster and resulted in fewer errors.  So, thusly, a better EMR design is better.

While it seems intuitively obvious - you still need studies to back up your justification for interface design in electronic medical records.  Their approach in testing is one I'd like to see expanded - and perhaps even implemented as a regulatory standard - evaluation on cognitive load and a certain level of task-based completion testing with error rates at a certain level.  Electronic medical records should be treated like medical devices/medications/equipment that should be rigorously failure tested.  While EMRs are far more complicated instruments, studies such as this one, illustrate that an EMR with interfaces designed for specific work environments to aid in effective and efficient task-completion save time and reduce errors.

The main issue I see with EMR these days is that the stakeholders and motivators behind this initial wave of implementation in financial - systems in place to capture every last level of service provided to a patient in order to increase revenues.  Now, the next generation and movement with EMRs is to look at how they can increase patient safety, particularly in light of threats of non-payment for preventable medical errors.  Again, financial motivation, but at least this financial motivation is going to motivate progress and maturation of medical records as tools to protect patients, not simply to milk them for profits.

Chest Pain and Recent Negative Stress Test

If your hospital is anything like our hospital, you have tons of low- and intermediate-risk chest pain.  Every one is stressful, but hopefully you have a friendly hospitalist, or better yet, an ED-run chest-pain unit that gives you a place for observation admissions.  They go there, get their rule-out, and get some sort of provocative test, as discussed in the most recent AHA guidelines.  The test is negative, they go home.

...and then they come back a week later with the same symptoms.

This is a great paper to have in your pocket when you need to justify why this patient still needs to be ruled out; I heard about it when it was mentioned on the April EM:RAP during the low-risk chest pain discussion.  Patients with negative stress tests may still be diagnosed with CAD on angiography - 20.7% incidence of CAD in their cohort which had negative or non-diagnostic stress within 3 years - and 7.8% were diagnosed with AMI.

When you add negative troponins and the negative stress from the previous visit, you've met the guidelines and standard of care to say they did not have acute myocardial ischemia and you cannot induce ischemia on provocative testing, and they are risk-stratified into a group of patients very unlikely to have ACS in the next 30 days/60 days/6 months.  However, you get that high NPV because you're performing these tests on a low-risk population, not because the sensitivity of those tests, particularly stress testing, is good enough.  While this patient likely does not need another provocative test - although, depending on individual factors, they may be candidates for angiography of some sort - if their story is concerning for cardiac etiology, they still need enzymatic rule-out.

Tuesday, April 12, 2011

Prehospital STEMI Diversion to PCI

Time is muscle and the earlier you get to PCI the more muscle you can save.  So, we should just drive by all the critical access hospitals and go straight to PCI-capable centers?  The Dutch, in this retrospective study, think we should.  Everything in their protocol hinges on EMS reading a computer interpretation of the EKG, and, if it says STEMI, they go to the PCI center.  At the end of the day, everyone who went to the PCI capable center first rather than the spoke hospital first had a mortality benefit between 2% and 2.6% at one year.  

What they really don't discuss much are the outcomes of the 5.7% of their intention-to-treat analysis that had false positives.  False positives, at least, are typically not harmful to the patient - the alternative diagnoses for chest pain that would benefit from immediate treatment at one of their non-PCI "spoke" hospitals are probably not that frequent - aortic dissections and submassive PEs tend to be the sorts of things that would benefit.  But, even if they did a true intention-to-treat analysis, they'd probably still have a mortality benefit.  The other problem with false positives is the financial costs associated with unneeded cath lab activation and the costs to the system associated with taking EMS out of service.  It's obvious that treating patients for their disease in the most timely fashion for certain diseases improves outcomes - but we must always beware of the unintended consequences.

This is actually a big deal sort of topic in EM right now as it relates to the regionalization of care, which is something that the Academic Emergency Medicine consensus conference is dealing with right now.  Attempting to mirror what's happened with trauma networks, they're trying to extend the benefits to other acute conditions that otherwise benefit from transfer to higher levels of care.  Clearly, a myriad of life-threatening conditions benefit from the resources of tertiary referral centers - but the logistics and political issues associated with centralizing care for different conditions remains a significant barrier.