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"
www.ncbi.nlm.nih.gov/pubmed/21403014

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."
http://www.dovepress.com/implementing-the-2009-institute-of-medicine-recommendations-on-residen-peer-reviewed-article-NSS

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"
www.ncbi.nlm.nih.gov/pubmed/21629150