Saturday, February 4, 2012

Safety-Nets & ED Length of Stay

This is a relatively intriguing public policy article in JAMA following up in a timely fashion regarding the new CMS Emergency Department quality measures.  These new measures include various time-to-X measures, including length of stay, length of time to admission from bed request, etc.  There is some concern that these quality measures may be tied to federal funding, unfairly targeting "safety-net" hospitals that are not at baseline provided with the resources to address patient flow issues.

This article is a review of the NHAMCS database, a national probability sample survey of patient visits, looking at independent predictors of increased length of stay in patients admitted and discharged from the Emergency Department.  Based on the review of this sample, they do not see a significant difference in ED length of stay - and conclude that these quality measures should not be of concern to "safety net" EDs.  However, these general time-based measures mask most of the problems encountered in "safety net" institutions.

There are some baseline differences in patient characteristics between the safety-net and non-safety-net hospitals in their sample, and they tend to work in favor of safety-net hospitals.  The safety net hospitals in this sample tended to have younger patients with lower triage acuities, which should work in favor of reduced ED overall average length of stay.  My anecdotal experience suggests that, once the quality measures track more detailed ED transit times, I believe we will see more significant deficiencies drop out in the safety-net group.

"Association of Emergency Department Length of Stay With Safety-Net Status"

Thursday, February 2, 2012

Half of Fractures Received No Analgesia

One of the new CMS quality measures involves measuring time to receipt of pain medication for patients diagnosed with long bone fractures.  While this isn't the most exciting quality measure in terms of outcomes, it is probably a reasonable expectation that fractures receive pain control, and it might be a plausible surrogate marker for overall Emergency Department operations - at least, until the powers that be focus solely on these few measures at the expense of other clinical operations.

This article is a retrospective review of all pediatric long bone fractures evaluated at their facility.  They used the electronic medical record to track the timing of any "adequate" pain medication.  They have a specific weight-based definition of "adequate" for IV narcotics, PO narcotics, and non-narcotic analgesics, and they specifically break down pain medication received within 1 hour of arrival.

They identified 773 cases in their records, and by their definitions, 75 patients received an "adequate" dose of pain medication within 1 hour.  One can quibble with their definition of "adequate" because there is a range of pain needs that don't necessarily require maximal dosing.  But, you cannot quibble with the fact that 353 children received no pain medication at all within an hour of ED arrival (or prior to ED arrival).  Certainly, some individual factors at play would result in reasonable delays to pain medication, but definitely not nearly half.

"Analgesic Administration in the Emergency Department for Children Requiring Hospitalization for Long-Bone Fracture"
http://www.ncbi.nlm.nih.gov/pubmed/22270501

Tuesday, January 31, 2012

Congratulations Michelle Lin!

One of the prominent medical education bloggers - who is really much more than just a great blogger - has been awarded an endowed chair by the University of San Francisco School of Medicine to support her medical education efforts.  This is notable to me because, in the press release, they specifically mention part of the mission of the award specifically notes "keep up her active 'Academic Life in Emergency Medicine' blog".  


It's fascinating to see how alternative publication sources and online media are influencing the perception of "academic achievement".  For instance, my JAMA commentary - a journal with Impact Factor of 30 - has been viewed as full text or downloaded as PDF ~2000 times in the last six months.  This blog, on the other hand, exceeds 400 views per day.  There's no question which has been more rewarding to my brief career so far.


Again, congratulations to Michelle!  Now she has to do, not just great things, but insanely great things!  (also, go Stanford!)


"Inaugural Academy Chair in Emergency Medicine"
http://medschool2.ucsf.edu/sfgh/news/inaugural-academy-chair-emergency-medicine

Dosing Errors With IV Acetaminophen

As a follow-up to the recent posting regarding IV acetaminophen, this recent article in Pediatrics highlights a few case reports regarding overdose.

According to the authors, the most frequent error in administration when the order is written in milligrams, but the medication order is administered in milliliters - a 10-fold overdose.  All of the patients in this series received n-acetylcysteine infusion, and none appeared to suffer significant liver injury specifically attributed to the overdose.

Another lovely demonstration of the potential for iatrogenic injury in healthcare.  Even the most apparently benign orders can have unanticipated harmful consequences, and a demonstration how intravenous administration is at higher risk.

"Intravenous Acetaminophen in the United States: Iatrogenic Dosing Errors"
http://pediatrics.aappublications.org/content/early/2012/01/18/peds.2011-2345.abstract

Monday, January 30, 2012

Scattering Tacks In The Road

I might be the only one who finds the irony in this, but, at long last, we have a rapid assay to estimate the activity of the new oral direct thrombin inhibitor, dabigatran.


Just to recap, with coumadin, we can measure PT/INR; for heparin, PTT; and for enoxaparin and its brood, (less rapidly) Factor Xa levels.


Now, we have the HEMOCLOT test.


Created and marketed by Boehringer Ingelheim, the manufacturers of dabigatran. (Edit: sorry!  This is not manufactured by Boehringer - they only published this study.  Boehringer is, however, working on a FAB antibody to dabigitran to use as an antidote, however.)


It's a beautiful piece of business to put a dangerous medication on the market, and then sell the only practical means of monitoring levels.


"Using the HEMOCLOT direct thrombin inhibitor assay to determine plasma concentrations of dabigatran."
http://www.ncbi.nlm.nih.gov/pubmed/22227958

Sunday, January 29, 2012

Further Harms of IV Contrast

Radiation: cancer.  Iodinated contrast: renal injury.  Now, iodinated contrast: thyroid dysfunction.

This is a retrospective, matched, case-control study performed in Boston to evaluate any association between CT administration of IV contrast and hyper- and hypothyroidism.  They gathered 178 new-onset hyperthyroid and 213 new-onset hypothyroid cases and statistically matched them in their patient database to euthyroid "controls".  There were no significant differences between the groups at baseline - although, they don't match between terribly many clinical variables.

In the end, they find the patients who developed thyroid dysfunction had higher rates of iodinated contrast exposure - primarily from cardiac catheterization, but also from CT scans.  For hyperthyroidism, 6.1% of controls had contrast exposure, whereas 10.7% of their hyperthyroid patients had received contrast.  For hypothyroidism, the numbers are 8.5% controls vs. 12.2% hypothyroid.

It's a bit of a backwards way to approach it - ideally they'd compare a group receiving iodinated contrast against a group that did not, and observe the incidence of thyroid dysfunction - but it seems that's not the format of data to which they have access.  In any event, the physiologic basis is reasonable for the association - more data needed to confirm these findings.

Just in case you needed another reason to not order a contrasted CT.

"Association Between Iodinated Contrast Media Exposure and Incident Hyperthyroidism and Hypothyroidism"
http://www.ncbi.nlm.nih.gov/pubmed/22271121