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.

http://www.ncbi.nlm.nih.gov/pubmed/21496143

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.

http://www.ncbi.nlm.nih.gov/pubmed/20970813

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.

http://www.ncbi.nlm.nih.gov/pubmed/21386079

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).

http://www.ncbi.nlm.nih.gov/pubmed/21336126

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.

http://www.ncbi.nlm.nih.gov/pubmed/21494106

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.

http://www.ncbi.nlm.nih.gov/pubmed/21494113