Monday, August 8, 2011

High-Risk Discharge Diagnoses

Good news - only 0.05% of your discharged patients will meet an untimely end within 7 days of the Emergency Department visit.  Not a frightening number, but definitely enough to keep you on your toes.

It's a retrospective Kaiser Health System cohort of 728,312 visits across two years, and the authors calculated the base rate of 50 per 100,000, as well as looking at other features and discharge diagnoses that increased the OR for death within 7 days.  And, even the sickest, most elderly have OR that are low enough that you're still going to have good outcomes the overwhelming preponderance of the time.  Age greater than 80 gives an OR of 10.6 and a score >3 on the Charlson Comorbidity Index gives an OR of 6.7.  As for the diagnoses they found that are most highly associated with bad outcomes - the only two with OR great than 5 are noninfectious lung disease (OR 7.1) and renal disease (OR 5.6).  These are kind of interesting buckets of diagnoses, specifically in the sense regarding how nonspecific they are - which the authors attribute to diagnostic uncertainty.  I.e., the reason why patients had bad outcomes with "noninfectious lung disease" is because clinicians missed finding the specific morbid diagnosis in these patients.

I don't think this is practice-changing news, since these rates are so low in general that additional testing and hospitalization will harm more people than these missed diagnoses - but it's an interesting number crunch article.

"Patterns and Predictors of Short-Term Death after Emergency Department Discharge"

Sunday, August 7, 2011

Against Medical Advice

This is a nice review article that shows a mix of different issues associated with signing a patient out AMA.  It's a strange practice environment we have here, where EM is turning into an increasingly customer-centric practice specialty - yet unless we have airtight documentation, our customers can litigate against us for the choices they make.

In principle, our patients have the autonomy to make their own decisions - but our cultural values have drifted away from accepting responsibility for our actions.  To best protect ourselves, the authors recommend using a specific AMA form - not because having the patient's signature on a form confers any extra legal protection, but because it's a structured document that helps remind clinicians to document the two key elements of the AMA:  that the patient had medical capacity to make the decision, and that the patient was adequately informed of the risks.   After you satisfy both those conditions, the key is simply complete documentation in the medical record, and you should be afforded some protection given the patient has now terminated the legal duty to treat and assumed the risk for further poor outcomes.

"The Importance of a Proper Against-Medical-Advice (AMA) Discharge"

Friday, August 5, 2011

Physicians Will Test For PE However They Damn Well Please

Another decision-support in the Emergency Department paper.

Basically, in this study, an emergency physician considered the diagnosis of pulmonary embolism - and a computerized intervention forced the calculation of a Wells score to help guide further evaluation.  Clinicians were not bound by the recommendations of the Wells calculator to guide their ordering.  And they sure didn't.  There were 229 patients in their "post-intervention" group, and 26% of their clinicians said that evidence-based medicine wasn't for them, and were "non-compliant" with their testing strategy.

So, did the intervention help increase the number of positive CTAs for PE?  Officially, no - their trend from 8.3% positive to 12.7% positive didn't meet significance.  Testing-guideline complaint CTA positivity was 16.7% in the post-intervention group, which, to them, validated their intervention.

It is interesting that a low-risk Wells + positive d-Dimer or high-risk Wells cohort had only a 16% positive rate on a 64-slice CT scanner - which doesn't really match up with the original data.  So, I'm not sure exactly what to make of their intervention, testing strategy, or ED cohort.  I think the take home point is supposed to be, if you you can get evidence in front of clinicians, and they do evidence-based things, outcomes will be better - but either this just was too complex a clinical problem to tackle to prove it, or their practice environment isn't externally valid.

Thursday, August 4, 2011

Should Rural Health Care Be Equivalent?

"All residents in the United States should have access to safe, high-quality health care and should have confidence in the health care system regardless of where they live."

That is the final statement of the accompanying editorial to the JAMA article documenting superiority in outcomes in urban hospitals vs. critical care access rural hospitals for acute MI, CHF, and pneumonia.  The acute MI study population is slightly more ill at baseline in the rural hospital sample, but the groups are otherwise similar.  Raw mortality is higher for AMI (26.1% vs 23.9% adjusted), CHF (13.4% vs. 12.5%) and pneumonia (13.0% vs. 12.5% [not significant]) favoring urban hospitals.

The key feature - critical access hospitals were less likely to have ICUs, cardiac cath, surgical capabilities, and had reduced access to specialists.  Is it any wonder their outcomes are worse?  As someone who moonlit in one of these hospitals as a resident, I can guarantee the standard of care in a rural setting is lower.

But, coming back to the original supposition - is it realistic to dedicate the funding and resources to bring rural hospitals up to the standard?  To equip far-flung hospitals with the same standard of care as urban settings to cover the remaining 20% of the population is likely simply an unfeasible proposition.  Living in rural areas is simply going to come with the risks associated with unavoidable delays in care and reduced access to specialists and technology.

"Quality of Care and Patient Outcomes at Critical Access Rural Hospitals"
"Critical Access Hospitals and the Challenges to Quality Care"

Tuesday, August 2, 2011

It's Impossible To Catch All Pediatric Pneumonia

Another glass half-full vs half-empty, depending on how you read it.  Their editor capsule summary says "Children without hypoxia, fever, and ausculatory findings are low risk."  The numbers say - in the absence of hypoxia, fever, or focal ausculatory findings, radiographic pneumonia was seen in 7.6% (CI 5.3-10.0).  Interesting numbers that, to me, say that pediatric pneumonia is still a black box of uncertainty.

However, what the authors call "definite" pneumonia was only 2.9% in the absence of those findings, and the editor's capsule conclusion is that low-risk patients are best served by follow-up rather than radiology.  And, this is where the half-full/half-empty comes in - because a lot of EPs don't want to the guy that sends home pneumonia even in a "low risk" situation, given than 30% of their pneumonia diagnoses required admission.  I'd rather take the half-full approach - recognizing that the majority of radiographic pneumonias are viral anyway, and, if the patient has adequate follow-up and tunes up nicely, do my best to avoid unnecessary testing in a low pretest probability setting that will end up with more false positives and unnecessary antibiotics.

"Prediction of Pneumonia in a Pediatric Emergency Department"

Monday, August 1, 2011

Does EHR Decision Support Make You More Liable?

That's the question these JAMA article authors asked themselves, and they say - probably.  The way they present it, it's probably true - using the specific example of drug-drug interactions.  If you put an anticoagulated elderly person on TMP-SMX and they come back a few days later bleeding with an INR of 7, you might be in trouble for clicking away the one important drug alert out of the one hundred you're inundated on your shift.  The authors note how poorly designed the alerts are, how few are relevant, and "alert fatigue" - but really, if you're getting any kind of alerts or have any EHR tools available to you during your practice, each time you dismiss one, someone could turn it around against you.

The authors potential solutions are an "expert" drug-drug interaction list or legislative legal safe harbors.

"Clinical Decision Support and Malpractice Risk."

Friday, July 29, 2011

"Narcotic Bowel Syndrome"

I had never heard this specific diagnosis bandied about in an Emergency Medicine context - but, essentially, it's a gastroenterology entity (and diagnosis of exclusion) that entails, essentially, chronic, intractable, crampy abdominal pain of unknown etiology and concurrent narcotic use.  I can't even describe how many of these patients I saw each shift during residency - and how many of those people had multiple CT scans in the past year.  The key feature in this particular diagnosis, as described in their case, is they had extensive follow-up evaluation, were weaned from their narcotics, and had resolution of symptoms.

I think this is a diagnosis spectrum we see a lot in the ED - whether it be constipation, IBS, cyclic vomiting syndrome, "feeling sick", or the multitudinous abdominal pain of unknown etiology.  With more and more patients being prescribed (or secretly taking) narcotics, what we see in our EDs is not just the overdose emergencies, but the various side effect spectrums of dependence and withdrawal.

You'd think that with all our medical technological prowess we'd have better mechanisms to treat pain than they did thousands of years ago.

"Narcotic Bowel Syndrome"

Thursday, July 28, 2011

Endotracheal Tube Verification Via Ultrasound

I think I've discovered the new paradigm of research in ultrasound.  Every time you do a procedure or make a diagnosis, slap the ultrasound on someone and see if you can reliably identify anatomic changes.

It looks like, with their practiced ultrasonographers, that they can get some preliminary information regarding endotracheal tube placement by performing transtracheal ultrasound.  Their "gold standard" was waveform capnography - which is a fair gold standard, but not universally sensitive and specific for tube placement in all clinical situations.  Essentially, if the ETT is in the correct place, there is only one "air-mucosal interface" observed with high-frequency linear probe, and, if the ETT is in the esophagus, you have a second, posterior air-mucosal interface.

Seems reasonable.

Experts did it correctly with 99% sensitivity and 94% specificity, and the main advantage was speed.

"Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube
placement during emergency intubation."

Tuesday, July 26, 2011

Online Publishing of ED Wait Times

When a small city only has two Emergency Departments, you can run a study like this to see what effect publication of ED wait times has on visits.

While it is fabulously logical that if 18 to 40 people a day are looking at your Emergency Department wait times that some portion of those people will choose a facility with a shorter wait time - or choose not to come to the ED at all - or choose to come in when they might not have otherwise come in if the wait time is short - this study doesn't actually try to study the population of interest.  They need to somehow capture individuals who are using the published information to make decisions, rather than looking generally at their overall wait time statistics - because, even though they say their results "were consistent with the hypothesis that the publication of wait time information leads to patients selecting the site with shorter wait time", they are making a huge unsubstantiated leap.

Looking at their descriptive statistics, hardly anything changed to actually justify their conclusions, and, really, it looks like patients just based their decisions pretty heavily on which of the two hospitals was closer - particularly Victoria Hospital, which people only went to if it was nearer.  I do also find it fascinating that their mean wait time rose from about 105 minutes to 115 minutes, yet the amount of time their wait time was >2 hours (120 minutes) actually dropped from 13% to 9%.  This is how they justify their conclusion that the "spikes" are mitigated by online usage - and it may be true - but there are too many moving parts and they aren't actually asking people if they used the website and used the information from it.

"The effects of publishing emergency department wait time on patient utilization patterns in a community with two emergency department sites: a retrospective, quasi-experiment design."

Monday, July 25, 2011

Facebook, Savior of Healthcare

This is just a short little letter I found published in The Lancet.  Apparently, the Taiwan Society of Emergency Medicine has been wrangling with the Department of Health regarding appropriate solutions to the national problem of ED overcrowding.  To make their short story even shorter, apparently, they ended up forming a group on Facebook, and then posting their concerns to the Minister of Health's Facebook page.  This then prompted the Minister of Health to make surprise visits to several EDs, and, in some manner, the Taiwanese feel their social networking has led to a fortuitous response to their public dialogue.

So, slowly but surely, I'm sure all these little blogs will save the world, too.

"Facebook use leads to health-care reform in Taiwan."

Friday, July 22, 2011

CTCA Studies Are Not Externally Valid

This is a multicenter study from Canada that looked at the diagnostic accuracy of computed tomographic coronary angiography using invasive coronary angiography as the gold standard - and they found that it's not bad.  Specifically, they found it was not bad at one of their four centers used in the study, and terrible at three of the four centers used in the study.  In a patient population with a pretest probability of CAD less than 50%, the AUC for CTCA was 0.951 at center 1, and 0.597 at centers 2, 3, and 4 combined.

So, clearly, the most important factor affecting the results of your CTCA is your institution's skill at performing and interpreting the test.  Which, if you take it one step further, means that unless your institution is a CTCA center of excellence like the ones pumping out the CTCA studies, you can't apply their results to your practice.  Specificity stays reasonable, but you lose a lot of sensitivity - and when the CTCA for low-risk rapid rule-out is predicated on the high NPV, you can't afford to lose sensitivity.

"Ontario Multidetector Computed Tomographic Coronary Angiography Study"

Thursday, July 21, 2011

"Time-Out" In The ED Is Nearly Universally Useless

...but still probably a good idea.

Out of 225 ACEP councillors responding to a survey, 5 knew of an instance in the past year where a time-out may have prevented an error.  So, a year's worth of personal patient encounters, plus whatever they heard about in their department, multiplied by 225 - which means we're looking at hundreds of thousands of patient encounters - and there were only a handful of events where a time-out would have helped.

That being said, time-outs have been a Universal Protocol with the National Patient Safety Goals since 2004 because performing the wrong procedure, at the wrong site, on the wrong patient really falls into a category of a "never event".  It does seem like a no-brainer in the ED, where the procedures we're performing on patients are specifically related to the unique presenting event, but errors still occur - and the magnitude of the harm to the patients who are being harmed is probably greater than the consequences of the additive delay in care to other patients from the cumulative time performing the time-out.

"A Survey of the Use of Time-Out Protocols in Emergency Medicine"

Tuesday, July 19, 2011

Residency Is Thinly Veiled Healthcare Rationing!

Apparently, we're still $376 million dollars short in funding just to meet the 2003 ACGME work hours regulations, in terms of hiring additional staff, etc.  So, of course, there should be no problem getting the remaining $1.4 billion needed to bring us up to date with the new rules.  And there's still the matter of these authors saying that's still not good enough.

They also say, more stick, less carrot.  For patients!  Think of the children!

Of course, they're probably right.  A lot of EM training is stressful, but it isn't barbaric.  We have enough off-service rotations to realize we're one of the relatively coddled residencies in brute terms of sleep deprivation and time away from the hospital.  My sister just finished her PGY-1 in general surgery by going Q2 into the break before 2nd year.  We're not in compliance, we're not operating at our peak abilities, and we're not exhaustively supervised.  Patients are harmed, no doubt.

But that's the reality of the funding situation and the budgets proscribed by Congress.

Now, if you want go out and inflame a mob, you could invoke this as part of healthcare "rationing", letting undertrained, barely-doctors practice on the sickest patients because we choose to allow a few people to be harmed to save money.

"Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety."

Monday, July 18, 2011

It's Not An Abscess (Yes It Is)

These studies pretty much all end up saying the same thing - academic faculty can't agree on the presence or absence of differentiating characteristics between abscess and cellulitis.  This particular study is in a pediatric population, and, there's a lot of kappa and absolute agreement to comb through in their tables, but, basically, about 20% of the time two attendings substantially disagreed.  The authors then follow this up by observing that an I&D was performed 75% time, and purulent material was found 92% of the time.

The best conclusion from this might be - if there's some ambiguity, put a scalpel in it.  I'd say this is reasonable - because we've seen a hundred times the child who bounces into the ED on day 3 of cephalexin for cellulitis because what he really had was a MRSA abscess to begin with.

Or, if you have an ultrasound with a high-frequency probe, you might be able to differentiate homogenous hyperemia from fluid collection.

"Interexaminer Agreement in Physical Examination for Children With Suspected Soft Tissue Abscesses"

Friday, July 15, 2011

Video Education For Emergency Departments

I know you can't get published if you say something like "Our intervention is probably not useful and serves only as a cautionary tale for other wayward sailors", but it still bothers me when you stretch the conclusions out by saying that an intervention that is probably not better than the control group "appears promising".

This is a group that looked at the best way to improve parent education in pediatric asthma encounters in the Emergency Department.  They compared a video-based education program to a written handout and didn't make much difference.  They had two groups of parents, those with "low health literacy" and those with "adequate health literacy".  The low literacy group improved a ton regardless of which educational modality was used.  The adequate literacy group barely budged with written and had a little bit more of bump with video - but the relative change in their level of literacy really wasn't anything to write home about and they don't try to offer an explanation for why intelligent people derive no benefit from written education.

But it doesn't stop them from stating it "appears promising" - which, I suppose, means it's probably better than not educating people at all, or potentially educating the illiterate.

"Parental Health Literacy and Asthma Education Delivery During a Visit to a Community-Based Pediatric Emergency Department."

Thursday, July 14, 2011

The Diagnose-a-Tron of the Future: FDG-PET

Imagine, if necessary, a case you see every hour in the ED - a child with a fever.  Wave a magic wand in triage, find the source of the fever, and let the doctor pick up the decision-making process advance from there.

This scenario is, of course, totally farfetched - after all, you still need a certain number of HPI and ROS elements before you wave the magic wand to bill at a higher level of service.

But, the principle - this is a fascinating article regarding the workup of "fever of unknown origin" in adults.  These 81 patients had fevers for 3 weeks without a satisfactory explanation, and their cases were retrospectively reviewed following referral to FDG-PET scans.  Essentially, any time this FDG-PET scan localized to an area of high uptake, it provided significant helpful localizing information regarding the underlying disease process.  Examples of diagnoses it identified were infectious endocarditis, tuberculosis, pyogenic spondylitis, graft infections, Takayasu arteritis, and a host of other fascinatingly difficult diseases to identify.

The main diagnostic drawback is that it is mostly only structurally/anatomically specific, not necessarily disease specific, so there is a lot to do in terms of clinical correlation with imaging findings.  And then there is the small issue where it's a nuclear medicine study requiring 5 hours of fasting and an injection of the FDG tracer 1 hour before the study is performed.  But, someday a decade out, the next generations of these devices might be more clinician-friendly....

"FDG-PET for the diagnosis of fever of unknown origin: a Japanese multi-center study."

Tuesday, July 12, 2011

5% of Patients Spend 50% of Our Healthcare Dollars

Per-capita spending doubled from 1997 through 2009 from $4100 to $8100 - with 5% of patients spending $35,800 on average annually to account for 47.5% of healthcare spending.  Overall, the five most expensive conditions are heart disease, cancer, trauma, mental disorders, and pulmonary conditions.

Unsurprisingly, people over 55 made up the majority of the high spending groups.  Unhappily enough, the authors note a "flattening" of the distribution of spending, where younger individuals are responsible for a greater proportion of the spending.  This is not due to more cost-effective care in the elderly, it's a result of increasing disease prevalence in the young, primarily attribute to obesity-related diseases such as hypertension, diabetes, hyperlipidemia.

May you live in interesting times, indeed.

"Understanding U.S. Health Care Spending - NIHCM Foundation Data Brief July 2011"

Monday, July 11, 2011

Send Children With Negative CTs Home

We should all love PECARN.  I love PECARN (Pediatric Emergency Care Applied Research Network) - and not just because I helped set it up as a research assistant peon before medical school.  I love it because it takes multicenter enrollment cohorts to conduct adequately powered research in a population that is rarely affected by serious morbidity and mortality.

Of 13,543 children with GCS 14 or 15 and a normal CT scan, none needed neurosurgical intervention in their follow-up period.  A small handful of these patients had a repeat CT or MRI for some reason, and between 10-25% of the hospitalized patients and 2-10% of the discharged patients had an abnormal result on repeat imaging.  None led to any intervention...which then, of course, begs the question whether it was appropriate to perform a test that did not result in meaningful change in management.  But, there's not enough patients in this group to draw conclusions as to whether repeat scans should or should not be performed.

My only caveat - when you take an over-utilized test in which nearly all patients are certainly fine and will continue to be fine, you actually dilute its external validity to the patient population that really matters.  However, even in a higher-risk patient population in which CTs are used far more conservatively, the clinically relevant answer is still going to be same - the only reasonable practice is still going to be to discharge these patients home.

"Do children with blunt head trauma and normal cranial tomography scan results require hospitalization for neurologic observation?"

Sunday, July 10, 2011

Groomsman Gifts

I bought all my groomsmen whiskey as gifts - at the world's largest liquor store, which is conveniently located 7 blocks from my new home in Houston.

Longrow 14 Year Old Sherry Cask Finish
It's a Campbeltown region Scotch whiskey that's a peatier version of the Springbank that I think is very nice.  Made by the same distillery in a limited run every year.

Suntory Yamazaki 18 Year Old
I posted once upon a time about the 12 year version of this whiskey, which is a Japanese whiskey aged in three types of oak cask.  I really liked the reasonably-priced 12 year, and I hope my best man will enjoy the 18.

Ardbeg Corryvreckan
Named after a famous maelstrom, it's a viscous, peaty Scotch whiskey for my friend who loves all things Islay.

Woodford Reserve Master's Collection
For my bride's brother, who prefers Bourbon whiskey, the seasoned oak finish Master's Collection edition.