Wednesday, November 30, 2011

ED Blood Pressure Management In Acute Stroke Is Terrible

This is a non-TPA article regarding the medical management of hypertension in acute ischemic stroke in the Emergency Department.

The authors remind us that for every 10 mmHg drop in SBP <150 mmHg, there is a 17.9% increase in risk for death at 14 days.  They additionally remind us that antihypertensive therapy is only recommended for BP >220/120 mmHg, with a 15-25% goal decrease in the first 24 hours.

This is a retrospective review of cases from 16 Cincinnati region hospitals looking at the blood pressure observed in the ED along with any treatment.  They found 1739 cases, 1520 of whom did not receive treatment and 219 who did.  It turned out that 2.6% of the non-treated patients should have had some blood pressure lowering - oops.  But, amazingly even worse, only 31.5% of patients who did receive treatment actually required lowering.

Of the 217 patients that were treated, 52 of them had greater than a 20% drop in blood pressure in the Emergency Department.  So, we treat a lot of blood pressure that shouldn't be treated - and when we treat it, it is not uncommon to treat it too aggressively.

Stop it!

"Emergency Department Adherence to American Heart Association Guidelines for Blood Pressure Management in Acute Ischemic Stroke"

Monday, November 28, 2011

Computer Reminders For Pain Scoring Improve Treatment

This is a paper on an important topic - considering the CMS quality measures coming up that will track time to pain medication for long bone fractures - that demonstrates a mandatory computer reminder improved pain treatment more than an educational campaign did.

This is a prospective study of 35,628 patients visiting an Australian emergency department in which they went through several phases of intervention, the most salient in their minds was requiring assessment of a pain score at triage.  They started by simply observing their performance, then they altered their electronic medical record with a mandated input of the pain score at triage.  After the mandated scoring, time to analgesia went from median of 123 minutes to 95 minutes.  After the mandate phase, the ED staff underwent an education program regarding pain management in the ED - and the time to analgesia didn't improve any further.

So, it is reasonable to infer that mandating the pain score at triage had the desired effect on decreasing time to analgesia.  However, 95 minutes until analgesia is still terrible.  It would be far more interesting of an article if it truly broke down all the times - such as time to triage, time to room, time to physician, time to analgesia order, etc., because there are a lot more data points to gather.

Additionally, it seems it might simply be higher yield if - in addition to asking pain in triage - they had a triage protocol to treat the pain immediately at that point, rather than later downstream.

"Mandatory Pain Scoring at Triage Reduces Time to Analgesia"

Sunday, November 27, 2011

False-Negative Abdominal CTs

This is an article from the radiology literature that essentially tries to say that CT is not the imaging modality of choice for upper abdominal pain.

It's a retrospective review of 235 patients over a four-year period who had CTs of the abdomen reported as "normal" or "non-diagnostic" in the setting of upper abdominal pain.  They determine false-negative studies if another diagnostic modality eventually provided a definitive diagnosis for the patient's symptoms.  Out of the 235, 81 were lost to follow-up and 27 were excluded for other reasons.  Of the remaining 127, 46 were classified as false-negative and 81 were classified as true-negative.

The misses?  23 cases of pancreaticobiliary disease (biliary colic, cholecystitis, choledocholithiasis), 12 cases of gastritis/gastric ulcer disease, and 6 miscellaneous cases that included Mediterranean fever and prosthetic valve endocarditis.

So, yes, there is some inkling that CT of the upper abdomen is going to miss a segment of pathology.  On the other hand, this paper presents incomplete data regarding the true positives and false positives - making evaluation of this specific imaging indication incomplete other than to remind clinicians that the evaluation may need to continue in the setting of a negative CT.

"Negative predictive value of intravenous contrast-enhanced CT of the abdomen for patients presenting to the emergency department with undifferentiated upper abdominal pain"

Friday, November 25, 2011

TPA Is "Safe" In Prior Stroke and Diabetics

Another recent Journal Watch article about TPA - relaying the manufacturer-sponsored message that TPA can, in fact, be given to the patients who were excluded from ECASS III because of diabetes or prior stroke.

Papers like this are fabulous.  I am 100% in agreement with the physiologic premise that timely reperfusion of the ischemic penumbra is beneficial in acute stroke.  I am less enthusiastic about using systemic thrombolysis, because it's akin to smashing a teacup with a sledgehammer.  But, until PCI-like therapy is available/safe for the brain, it's all we have.

I am really tired of endless papers from the TPA literature with authors falling all over themselves to present fundamentally flawed data as definitive evidence.  In this paper, the authors take the non-randomized TPA population from the SITS-ISTR - and compare it to the non-randomized, non-thrombolyzed population from the VISTA registry.  Why is this a problem?  Because even though the relative differences are large, the absolute differences are small - and we've already see that what makes the largest absolute difference is stroke after-care, and that all stroke centers are not created equal.  The authors acknowledge this, but then justify their results by stating that their numbers are similar to prior, retrospective, non-randomized comparisons performed on subsets of registry data.  It's a self-fulfilling prophecy.

They conclude with "Hence, we find no justification to exclude patients from receiving alteplase for acute ischemic stroke if they have a [prior stroke] and also have [diabetes mellitus]" - which is true, unless it bothers you that the mRS 6 (dead) group nearly doubles when TPA is given to the stroke/diabetes groups.  Imagine what the reaction to ECASS III would be if TPA wasn't 52% good outcome vs 6.7% death - and was one of these 29% good outcome vs. 23% death, or 25% good outcome vs. 28% death comparisons from the registry data (totally different baseline severity vs. ECASS III, just throwing the numbers out there for hyperbole).

...and, the obligatory:

"Dr. Mishra reports no disclosures. Dr. Ahmed is an employee of SITS International, which received a grant from Boehringer Ingelheim for the SITS-MOST/SITS-ISTR study with alteplase. Dr. Davalos has received speaker or consultancy honoraria from AstraZeneca, Boehringer Ingelheim, Lundbeck Inc., ev3, Ferrer, and Talecris Biotherapeutics. Dr. Iversen has served on scientific advisory boards for Boehringer Ingelheim and Allergan, Inc.; and has received research support from the Danish National Advanced Science Foundation. Dr. Melo reports no disclosures. Dr. Soinne serves on speakers’ bureaus for and has received speaker honoraria from Boehringer Ingelheim, Pfizer Inc, and Siemens; and has served as a consultant for Boehringer Ingelheim. Dr. Wahlgren serves as Chairman of the SITS Scientific Committee; has served on scientific advisory boards for Boehringer Ingelheim and ThromboGenics NV; has received funding for travel and speaker honoraria from Boehringer Ingelheim, Lundbeck Inc., and Ferrer; and serves on the editorial boards of Stroke and Cerebrovascular Diseases. Dr. Lees serves on scientific advisory boards for Boehringer Ingelheim, Talecris Biotherapeutics, Lundbeck Inc., Ferrer, and PhotoThera; and has received speaker honoraria from Boehringer Ingelheim, Lundbeck Inc., ThromboGenics NV, and Talecris Biotherapeutics."

I want to use TPA to treat stroke without reservations, but the literature is broken.  Still hoping IST-3 will help define a low-risk population that benefits.

"Thrombolysis outcomes in acute ischemic stroke patients with prior stroke and diabetes mellitus"

Thursday, November 24, 2011

We Overestimate CAD Pretest Probability

The ACC/AHA clinical practice guidelines have a set of reference values for the pretest probability of >50% stenotic coronary artery disease based on the type of pain and age.  These values range from 2% in a 30 year old woman with non-anginal pain to 94% in a 60 year old man with typical angina.

And, turns out, this is way off.

This is a CTCA registry study of patients undergoing coronary angiography, 14,048 consecutive patients with suspected CAD, looking at both the incidence of 50% luminal narrowing (clinically interesting) and the incidence of 70% luminal narrowing (potentially flow-limiting), and correlating it to asymptomatic, non-anginal, atypical angina, typical angina, or "dyspnea only".

The meaningful tables of results somewhat defy summarization, but, they have plenty of hypertensives with dyslipidemia - but not very many diabetics or smokers - in their cohort.  In the end, however, none of the observed CAD was anywhere close to the predicted pretest probabilities.  The cohort with the highest prevalence of CAD was the typical angina in age 70+ males - but even that led to only 53% having a 50% lesion.  More than anything, age and gender the most significant predictors of CAD - with no population of women having greater than 29% incidence.

It's an interesting table worth looking at - CAD really doesn't kick in until after age 40, and, even then, only mostly in men, and, even then, only in patients with typical symptoms.  Once you hit age 50 in men, however, there's CAD everywhere, even with atypical (or no) symptoms.

There was also some variability by study site - with the 2,225 from Korea having very little CAD and the 29 from the Swiss site having markedly more, but the remainder are relatively similar.

I love studies that just present reams of data and don't try to push any particular sponsored agenda.

"Performance of the Traditional Age, Sex, and Angina Typicality–Based Approach for Estimating Pretest Probability of Angiographically Significant Coronary Artery Disease in Patients Undergoing Coronary Computed Tomographic Angiography"

Tuesday, November 22, 2011

Another Call to Retire Dopamine

The slow, gradual shift from dopamine to norepinephrine as the vasopressor of choice in septic shock has another piece of ammunition - this time a meta-analysis of the observational and randomized trials.

They perform two separate analyses - an analysis of five observational trials and an analysis of six randomized trials.  They find heterogeneity and no difference in the observational analysis - and then drop the observational trial responsible for the heterogeneity, and find an RR for mortality of 1.23 favoring norepinephrine.  Then, with the randomized trials, they find an RR for mortality of 1.10 favoring norepinephrine.  The RR for arrhythmias associated with dopamine use was 2.34 in their pooled analysis.

Of the RCTs, most of the patients came from one trial with 1044 patients and includes four trials with fewer than 50, so it's not exactly as though this analysis adds a lot of statistical power - but it's enough to reinforce the trends from each trial.

It is reasonable to suggest that norepinephrine is superior to dopamine - but I would also suggest the magnitude of that difference, given the data we have so far, has only been shown to be small.

"Dopamine versus norepinephrine in the treatment of septic shock: A meta-analysis"

Monday, November 21, 2011

Prolonged QT - Don't Believe The Hype?

Much ado is made about the risk of QT prolongation and the development of malignant arrhythmias, particularly Torsades de Pointes - but how frequently does TdP actually occur in these patients who QT prolongation?  Should we be worried about every EKG that crosses our paths with a prolonged QT?

It seems, like so many things, the answer is yes and no.  This is a prospective observational study from a single institution that installed cardiac monitoring that enabled minute-by-minute measurement and recording of QT intervals in their monitored inpatient population.  They evaluated 1,039 inpatients for 67,648 hours worth of time, and found these patients spent 24% of their monitored time with a prolonged QTc (>500ms).  One single patient had a cardiac arrest event where TdP was evident on the monitoring strip - a comorbidly ill heart failure patient whose QTc ranged as high as 691ms.

The authors then went back to attempt to determine whether the prolonged QT was associated with all-cause mortality with the 41 patients who died during their study period, and they found that 8.7% had QT prolongation versus 2.6% who did not.  However, as you can imagine, there are massive baseline differences between the QT prolonged population and the non-QT prolonged population, many of which contribute greater effects to in-hospital all-cause mortality.  The authors attempt logistic regression and finally come up with an OR of 2.99 for QT prolongation for all-cause mortality - which is lower in effects than CVA, obesity, pro-arrhythmic drug administration, and high serum BUN.

It's reasonable to say that patients with a prolonged QT are at higher risk for death - but it's also reasonable to say that sick patients at a higher risk of death are more likely to have a prolonged QT.  Torsades was rare, even with the thousands of hours of QT prolongation noted.  I would not get over-excited about QT prolongation in isolation, but, rather, only in the context of multiple risk factors for mortality in acute illness.

"High prevalence of corrected QT interval prolongation in acutely ill patients is associated with mortality: Results of the QT in Practice (QTIP) Study"

Saturday, November 19, 2011

Health Information Exchanges Might Save Money

Though, from this data, it's not clear through what mechanism.

This is an retrospective billing database evaluation of Memphis Emergency Department visits between 2007 and 2008.  In Memphis, 12 EDs participate in an online data repository, which may be accessed by secure web connection.  The authors compared patients presenting to the Emergency Department for whom this medical record was accessed to patients for whom this record was not.

There were no baseline differences between the demographics of the study groups, although, this retrospective evaluation cannot account for the factors contributing to why physicians chose to access the information exchange for individual patients.

The results are rather odd.  The authors cite cost savings as a result of an OR of 0.27 for inpatient hospitalization after accessing the information exchange.  However, the frequency of basically every other type of activity stayed flat or increased - in fact, the OR for Head CT was 5.0 and a chest x-ray was 4.3 if information exchange records were accessed.

More tests?  Fewer admissions?  I'm not sure it's practical to generalize the effects of an information exchange on medical decision making in a retrospective fashion such as this.

"The financial impact of health information exchange on emergency department care."

Friday, November 18, 2011

Skipping the LP in Infants 30-90 Days - Eh.

This is another one of those "practice-changing" types of articles, where the authors try to debunk some specific aggressive diagnostic or therapeutic modality that is over-utilized in a low-prevalence, high-risk population.  This article, which you may have already seen, is regarding the need for a lumbar puncture in infants between 30 and 90 days.

They perform a retrospective review of nonconsecutive infants between 30 and 90 days of age who presented to the Emergency Department and received the "septic workup" - urinalysis/culture, blood culture, and lumbar puncture/CSF culture.  They analyze a data set of 392 infants, the overwhelming majority of which are completely culture negative.  52 of them are culture positive on their urinalysis, 13 are culture positive in the blood, and 4 are CSF culture positive.  The authors note that only one patient who had a positive urinalysis also had a positive CSF fluid culture – and that infant did not qualify as a low-risk infant by the Rochester criteria – so a well-appearing infant with a positive urinalysis need not undergo LP.

So, essentially, this study tells us only that meningitis is rare and that UTIs are common.  The authors attempt to make the flawed logical argument against LP in their discussion by emphasizing the negative predictive value for meningitis in the setting of an abnormal UA is 98.2%.  However, they erroneously discount the negative likelihood ratio of 0.87 (95% CI, 0.5–1.5).  Therefore, statistically speaking, based on their results, repeating this study 100 times could lead to nearly half the study results showing a positive urinalysis favored concomitant meningitis.

Now, in a clinical sense, the authors are likely correct.  An infant who looks well, meets the Rochester criteria, has an identified source for fever, and will be receiving antibiotics is at low risk for meningitis – by prevalence alone, not by anything this study shows – and is probable to have a good clinical outcome since they're receiving antibiotics (in the event that same organism is resulting in a well-appearing, subclinical systemic and cerebrospinal bacteremia).  The argument should not be that you can generate a zero-risk population with their combination of +UA and Rochester, but that the risk of bad outcome may be similar to the risk of harms associated with the lumbar puncture, false positives, and follow-on treatment/testing.

"Is a Lumbar Puncture Necessary When Evaluating Febrile Infants (30 to 90 Days of Age) With an Abnormal Urinalysis?"

Wednesday, November 16, 2011

ED Nursing Hand-Offs & Stroke Outcomes

Yet again, in the "little things matter more" series of dull, but important, Emergency Department literature.  TPA or no, what matters more in terms of their ultimate outcome is everything that happens down the line.

This is a retrospective review of consecutively-collected prospective registry data for acute ischemic stroke patients in Louisiana, looking at patients who were present in the ED during shift change.  They simply reviewed and compared the outcomes of 366 consecutive patients, looking at good outcome, neurologic worsening, discharge status, and development of pneumonia.

There are, unfortunately, huge, irreconcilable differences between the shift-change and non-shift change groups - the group that was in the ED had milder strokes and was less likely to have TPA 9.5% vs. 4.5% - but still ended up developing more pneumonia.  After their mathematical adjustments for various baseline differences, being present during shift change ended up with a five-fold increased odds of developing pneumonia, resulting in decreased likelihood of discharge to home or rehab.  The authors attribute this primarily to non-adherence with stroke unit dysphagia precautions, which is probably reasonable.  This is just retrospective and observational, but it probably identifies an important operations issue for the Emergency Department.

So, perhaps it does matter whether you give TPA or not - if TPA gets them out of the ED faster, that will help more than anything.

"Emergency Department Shift Change Is Associated With Pneumonia in Patients With Acute Ischemic Stroke"

Tuesday, November 15, 2011

The Cure For Bleeding is More Bleeding?

Intraventricular TPA for intraventricular hemorrhage - I wouldn't call it counter-intuitive, but I would certainly call it unusual.

This is a small placebo-controlled, randomized, blinded, prospective trial enrolling 48 patients with intraventricular hemorrhage requiring placement of an intraventricular catheter for CSF drainage.  They were testing the theory that low-dose TPA would assist in clot breakdown, thus speeding recovery.  There are probably not significant differences between groups - although the placebo group was oddly mostly women.  Also fascinatingly, the predicted mortality of each group was ~74% - and ended up being 23% in the placebo group and 19% in the TPA group.  Serious adverse events including 61% in the TPA group and 36% in the TPA group.  Due to the small sample size of the cohort, none of these differences reached statistical significance.

Unfortunately, the screaming major flaw in this study is that they do not truly have a control group - a true control would be standard care without the use of placebo administration through the intraventricular catheter.  Their rate of ventriculitis (8% and 9%) is higher than the typically expected rate for intraventricular catheter placement (probably below 5%), and is consistent with prior studies that showed increased incidence of ventriculitis when the catheter is used for administration of drugs or irrigation.  So, the safety profile and minimal outcome trend in favor of the TPA group can't truly be evaluated because it isn't being compared to the current standard of care, which is leaving the catheter alone for drainage only.

The authors conclude these results support further evaluation - which is already ongoing in the CLEAR III trial - and that the treatment met their pre-defined safety profile cut-offs.  Unfortunately, yet again, propagating their skew on the data is motivated by financial interests - Johns Hopkins has applied for a use patent and Genentech is behind the rtPA licensing and funding.  

"Low-Dose Recombinant Tissue-Type Plasminogen Activator Enhances Clot Resolution in Brain Hemorrhage"

Sunday, November 13, 2011

Big Pharma Is Behind The Money Hemorrhage

This is a research letter from the Archives of Internal Medicine that received a good deal of press recently, examining exactly where in the health system we were wasting money.

They focused on the ambulatory setting, used the NAMCS/NHAMCS database, and evaluated for the activities identified in the "Good Stewardship Working Group" identified by consensus to be low-yield and unnecessary.  They considered this to include antibiotics for afebrile/non-strep pharyngitis, routine EKGs, CT and MRI for uncomplicated low back pain, DEXA scans for young women, etc.  And they found - and this is where the big story comes in - $6.7 billion in these consensus not-recommended activities.

Fortunately for our Internal Medicine and Family Medicine colleagues, they actually weren't ordering a lot of unnecessary tests - $175 million for low back pain and $527 million for DEXA are a lot of money, but still a drop in the bucket.  The majority of the unnecessary activities, $5.8 billion of the total $6.7 billion, was writing for a brand-name statin (atorvastatin or rosuvastatin) instead of one of the generics.

Certainly just the tip of the iceberg.  Drug reps are more than earning their salaries, apparently.

"'Top 5' Lists Top $5 Billion"

Saturday, November 12, 2011

When Parents Refuse a Septic Workup

This is a brief commentary and discussion regarding the implications of parental refusal of hospitalization and evaluation of a potentially septic neonate.  It is absolutely an issue we all hope to never face, but probably will at some point in our careers.

Two pediatricians offer differing opinions on the extent to which social work and child protective services need be involved, raising such issues as the threshold percentage for likelihood of serious bacterial infection/bacteremia should be for "imminent harm" to the child, and the perceived benefits of therapy.  No specific answers are gleaned from the article, but it is worth reading and thinking through the discussions you would have in a similar situation.

"When Parents Refuse a Septic Workup for a Newborn"

Thursday, November 10, 2011

Ethanol - Miracle Drug (For Stroke)

From China, in Stroke, an animal model (poor rats, as usual) of MCA ischemia, collagenase-induced ICH, and post-TPA ICH.  Rats received either 0.5 mg/kg, 1.0 mg/kg, or 1.5 mg/kg ethanol after two hours of MCA occlusion.  Performance on various foot, balance, and parallel behavioral testing significantly favored the ethanol treatment group with initial and sustained reduction in errors as compared to the no-treatment group.

No difference was found between groups in induced ICH volume, and in their (small) series, no increase in ICH after TPA administration.  A transient increase in expression of hypoxia-inducible factor 1-alpha favoring ethanol was seen at 3 hours after reperfusion, gone by 24 hours.

I cannot wait to see the day where we give IV ethanol for acute stroke.

"Beer, the cause and solution to all the world's problems."

"Neuroprotective Effect of Acute Ethanol Administration in a Rat With Transient Cerebral Ischemia"

Wednesday, November 9, 2011

Computers - Probably Better Doctors for UTI

Uncomplicated urinary tract infections are probably one of the diagnoses that Emergency Physicians handle the worst - if they come to the ER, they're likely to get some sort drawn-out testing, whereas, if they went to their regular physician or called the nurse hotline, there would be antibiotics waiting for them at the pharmacy before they finished talking.

This is a prospective study in which patients with possible UTI were referred to a triage kiosk to complete a standardized computer questionnaire.  624 patients with possible UTI interacted with the kiosk - and unfortunately, only 103 qualified for the study by having enough features of typical, low-risk illness.  Patients were then randomized to protocolized antibiotic prescription as reviewed by a triage physician or usual care.

The good news - the kiosk saved a lot of time (89 minutes vs. 146 minutes).  The bad news - there were only 41 patients  followed-up in the intervention group and 26 followed-up in the control group, so we end up with only a tiny number of patients in each arm.  The kiosk group received more antibiotics for negative urine cultures than the control group (93% vs. 67%), so there is some additional element of harm secondary to antibiotic exposure - and, with a limited protocol, there are potential misses - and this study isn't large enough to identify them.

But, really, uncomplicated, typical UTI symptoms in women shouldn't be rocket science - and you shouldn't necessarily be doing any testing.  I would say the computer is a better physician - except, it would be absolutely simple for a physician to simply narrow their approach to match the efficiency of the kiosk with, in theory, some added skill.

"A Randomized Trial of Computer Kiosk–expedited Management of Cystitis in the Emergency Department"

Tuesday, November 8, 2011

Conflict of Interest in TPA Literature

Another tiny bit of self-promotion - a new publication published today.  Stems essentially from a literature review I did after clawing through ECASS-III and noting that 12 of the 14 investigators were paid, sponsored, or employed by the manufacturers of alteplase - which muddied my estimation of the reliability of the conclusions.  Turns out, ECASS-III wasn't the only one....

"Pharmaceutical Sponsorship Bias Influences Thrombolytic Literature in Acute Ischemic Stroke"

Monday, November 7, 2011

Resident Productivity Does Not Predict ABEM Scores

Simple, single-institution study of 11 years of resident in-service scores, patients-per-hour, and ABEM qualifying examination scores - and, as previously shown, only PGY-3 in-service examination scores predicted ABEM oral and written examination scores.

Simulated oral board examination scores did not correlate with ABEM oral examination scores, and the relative number of patients-per-hour had no significant correlations between any testing.

I would say that bears out my observational experience - doing more has no bearing on whether you might be doing more incorrectly.

"Outcome Measures for Emergency Medicine Residency Graduates: Do Measures of Academic and Clinical Performance During Residency Training Correlate With American Board of Emergency Medicine Test Performance?"

Good luck to everyone taking their ABEM exam today!

Sunday, November 6, 2011

CTA Contrast Probably Increases ICH With TPA

...although the authors of this study draw the opposite conclusion.

In an effort to decrease the administration of TPA to stroke mimics and TIAs, some institutions are moving to the use of CT angiographic and perfusion studies after the initial non-contrast scan.  Previous studies have suggested an association between iodinated contrast administration and ICH after TPA.

These authors beg to differ.  In their study cohort, they retrospectively evaluate 319 patients receiving TPA for acute stroke, 69 of whom receive contrast and 243 who do not.  Depending on whether the ECASS or SITS-MOST definition of symptomatic ICH is used:
 ECASS - 4 of 69 (5.8%) with contrast, 12 of 243 (4.9%) without contrast
 SITS-MOST: 3 of 69 (4.4%) with contrast, 9 of 243 (3.7%) without contrast

...and that small absolute difference does not reach statistical significance because their numbers are so small.  This does not prevent the authors from stating "we found no association of either IV contrast administration or contrast dose with SICH in our series of patients treated with IV rtPA."  They're not wrong - but they barely address how underpowered their study is, or how every baseline characteristic (age, stroke severity, comorbid conditions) favored their contrast group, yet they still trended towards increased ICH.

Does the author of every TPA article live in a distortion field that blinds them to reasonable consideration of safety issues and study limitations?

"Iodinated Contrast Media and Cerebral Hemorrhage After Intravenous Thrombolysis"

Friday, November 4, 2011

Predicting Deterioration After Admission

This is a decidedly unsexy topic that I guarantee your Medical Director or QI committee cares about a lot.  Particularly where I work, we occasionally have a prolonged boarding event, the patient isn't reassessed in a certain time frame, the patient is transported out of the ED - and they arrive on the floor or step-down and Rapid Response is called for an unanticipated escalation in care.

This is apparently a bigger deal in the United Kingdom, because it is recommended by their government hospital body to employ a risk-stratification system to predict patient deterioration.  These two articles discuss the derivation in the UK and the validation in Canada of the "ViEWS" score, which is named in part by from their electronic health record that stores their physiologic data.  The general gist of the system is that the authors of the first article derived a score incorporating pulse, respiratory rate, temperature, systolic BP, O2 saturation, whether patient was on oxygen, and a measure of CNS alertness.  They then compare it do several other scoring systems and amazingly enough, the scoring system they derive - using the system from the company the authors' wives work for and in which they own shares of stock - works better than the other systems.

An abbreviated version of this is put into validation at a Canadian hospital that does not use any of the equipment, or have any financial conflict of interests.  They found equally good results - which, in summation they give as four risk-stratification groups:
 - < 3 points: 65% of all patients, only 0.02% died within 48 hrs.
 - 3-6 points: 28% of all patients, 0.41% died within 48 hrs.
 - 7-10 points: 6% of all patients, 3% died within 48 hrs.
 - >11 points: 0.7% of all patients, 13.8% died within 48 hrs.

So, yes, we all can probably look at the patients scoring >11 and know they're sick without a scoring system.  However, this might be a model to look at with nursing staff to help change the parameters for floor beds or to reassess which patients can be downgraded in order to free up more intensive resources upstairs.  Just don't necessarily buy the product being hawked by the original authors.

"ViEWS—Towards a national early warning score for detecting adult inpatient deterioration."

"Validation of an abbreviated VitalpacTM Early Warning Score (ViEWS) in 75,419 consecutive admissions to a Canadian Regional Hospital"

Thursday, November 3, 2011

Medication Errors During Resuscitation

According to previous literature from 2002, up to 19% of medication doses are administered in error to hospitalized patients.  Presumably, we've improved.

Apparently, we haven't.  This is a prospective observational study by pharmacists in Pittsburgh who observed the inpatient Medical Emergency Team in operation - which in this instance, was a physician-led team with "full" critical care capabilities, as opposed to their non-physician Rapid Response Team.  They observed medication administration during 50 of these calls and found that there were 1.6 errors per medication administration.  Yes, they really observed more than one error per dose - but 66% of those issues involved aseptic technique.  Subtracting those, they observed an error merely every other dose.  46% were prescribing errors, 28% administration technique, 14% mislabeling, 10% preparation, and 2% improper doses.  The authors eventually conclude that 14% of the total non-aseptic errors were truly harmful, not just "errors".

Despite the small sample size, I think it's a fair assessment that "medical emergency" situations can be chaotic and error-prone - and we still have a ways to go to implement systemic changes to prevent errors.

In the end, the pharmacists' solution is - more pharmacists.  Hmmm....

"Medication Errors During Medical Emergencies in a Large, Tertiary Care, Academic Medical Center"

Tuesday, November 1, 2011

Dabigatran Worsens/Does Not Worsen Bleeding

Stroke and Circulation are both Journals under the umbrella of the American Heart Association.  So, when they publish articles that come to contrasting conclusions, I find that entertaining.

Both of these articles are mouse models of bleeding on dagibatran, C57BL/6 or CD-1 mice.  Sadly, they are frighteningly complex in their adjustments and statistical analyses - which means it defeats my ability to concisely summarize the findings and methods.

In short, one of these articles looks at intracranial hemorrhage after collagenase injection for mice receiving several different doses of oral dabigatran, and compare it to controls, warfarin, lepirudin, fondaparinux, and heparin.  It appears, and the author's final conclusion is, that dabigatran is the least harmful of all anticoagulants - about halfway between controls and the other anticoagulants.  They also shoot the mice with lasers in another portion of the study, and dabigatran "wins" that as well.

The other article looks at trying to reverse dabigatran - which, if you recall the human study I posted a few weeks back, was not successful in humans.  However, human trials were all surrogate markers of bleeding as measured by laboratory measurements of clotting.  What entertains me is, in contrast to the other study, these authors have no trouble inducing bleeding and significant ICH formation with dabigatran.  In any event, once the mice were adequately bleeding, the authors compared prothrombin concentrate complexes (specifically, Beriplex), FFP, and FVIIa for treatment of ICH 30 minutes after induced injury with collagenase.  Happily, PCCs, in a dose-dependent manner, attenuated the induced ICH, while the others failed.

So, perhaps this "novel, reversible" anticoagulant has a treatment option for life-threatening bleeding.  Human confirmation, at least case reports, needed.

"Anticoagulation With the Oral Direct Thrombin Inhibitor Dabigatran Does Not Enlarge Hematoma Volume in Experimental Intracerebral Hemorrhage"

"Hemostatic Therapy in Experimental Intracerebral Hemorrhage Associated With the Direct Thrombin Inhibitor Dabigatran"