Category: Quality

One-Man Crusade For Steroids In Spinal Trauma

The Cochrane Review regarding the efficacy of steroids in acute spinal cord injury, first published in 2002, has been updated for 2012.  The author’s conclusions: “Methylprednisolone sodium succinate has been shown to enhance sustained neurologic recovery in a phase three randomized trial, and to have been replicated in a second trial.”


This is an interesting conclusion to draw from an analysis of, essentially, only negative studies.  NASCIS 1 (1984) was statistically negative – but was discounted because the dosing was possibly too low.  NASCIS 2 (1990) was also statistically negative, except for pinprick and light touch at six months, which disappeared at one year.  The supposed positive outcome comes from a post-hoc analysis in which the patients who received their steroids between 3 and 8 hours after injury shook out to have a statistically significant improvements in motor score at six months and one year.  However, post-hoc subgroup analysis cannot be considered practice-changing evidence until confirmed in subsequent studies.  Otani (1994) was statistically negative for the primary outcome, but post-hoc analysis identified greater sensory improvement in the steroid group – which therefore implies greater motor improvement in the control group, as the overall combined neurologic scores were not different.  NASCIS 3 is not placebo-controlled.


There is also no mention in the Cochrane Review of adverse events – the only mention of the safety profile of high-dose steroids in the discussion section references a systematic review of high-dose steroids given to general surgical patients, both elective and trauma.  This is rigorously invalid, as the correct assessment of the safety profile of an intervention should be derived from the safety outcomes of the studies included in the analysis – nearly all of which had consistent, non-significant (underpowered) trends towards increased infectious complications.


Would it surprise you to discover that the author of the 2000, 2002 and 2012 Cochrane Review articles is the same first author of NASCIS 1, 2, and 3?

“Steroids for acute spinal cord injury.”

Everyone Loves “Art”

Apparently, rather than spend a lot of money on the back-end with patient satisfaction initiatives, all you really need is soothing artwork in your ED waiting room.


This is a rather simple, prospective cohort study in which research associates observed the waiting room behaviors of waiting patients.  They observed several different behaviors, but mostly were interested in “disruptive” behaviors – fidgeting, aggressive behavior, pacing, getting out of seat, etc.  After initial observation, artwork of “natural beauty” along with a DVD of soothing nature scenes was introduced into the waiting room of the two EDs in the study.


And, essentially, the ED waiting experience appeared more pleasant, according to their surrogate measures of patient disruptive behaviors – significant improvements in reducing out of seat behavior, fidgeting, front desk inquiries.


So, art?  Probably good, although this is a relatively methodologically weak study.


“Impact of Visual Art on Patient Behavior in the Emergency Department Waiting Room.”
http://www.ncbi.nlm.nih.gov/pubmed/22325555

An Overblown Critique of CMS OP-15

OP-15 for imaging effectiveness in atraumatic headache is coming, vigorously opposed by many.  To date, most of the opposition has been in principle, or with specific clinical concerns.

This is a different approach to the problem – looking at whether the patients that CMS identified as “inappropriate” were actually appropriate exceptions.  This was a retrospective chart review of 748 charts that were referred back to 21 hospitals as “inappropriate” following a “dry run” of OP-15.  Based on individual chart review, the authors found documentation of one of the exclusion criteria in 489 of them – 479 based on the clinical criteria, and 35 based on administrative criteria (some met both).  They then look at those 259 patients for whom there is no CMS exception for their CT, and they claim that 136 of those were clinically warranted.  They therefore conclude that only 125 of the original 748 were accurately identified by this quality measure as inappropriate use of CT in atraumatic headache, and that this measure is garbage.

And, a quick Google News search finds an extensive parade of indignant headlines pulled from ACEP’s press release, condemning the measure.

But, this study misses the point.  It’s not CMS’ responsibility to comb through individual charts to find these exclusion criteria.  The onus is on clinicians and hospitals to ensure their documentation clearly expresses the indications for CT in those cases that meet the exclusion criteria, and the purpose of this dry run is to help hospitals identify where the information they are supplying to CMS is deficient.

Then, I expect CMS to take a low opinion of the additional patients in whom these authors felt the imaging was clinically warranted.  Of the 78 patients for whom the authors felt ACEP guidelines for imaging were met, 73 of them met only the Level C recommendation: >50 years of age with a new type of headache and a normal neurologic examination.  Then, there is another set of patients with headaches on warfarin, who had recent neurosurgery, or had known hydrocephalus that they claim are misclassified by CMS – but I can’t see how the misclassification isn’t on the documentation end, as headaches in all those patients should meet ICD-9 339.44 “Other complicated headache syndrome,” which is an exclusion to the rule as well.

So, even just on first pass, I’m not sure this is an effective tool with which to influence revision of OP-15.  I expect this measure to go into effect as planned – and it will be up to us to document appropriately and thoroughly, and then to monitor and demonstrate that compliance results in measurable patient harms.

“Assessment of Medicare’s Imaging Efficiency Measure for Emergency Department Patients With Atraumatic Headache”
http://www.annemergmed.com/webfiles/images/journals/ymem/FA-JDSchuur.pdf

Patients: More Satisfied, More Dead?

Another article pulled out of the mainstream media – and one that highlights an issue many are familiar with: patient satisfaction.  There isn’t an ED out there whose medical director doesn’t know their patient satisfaction scores, whether Press-Ganey or their own evaluations, and many EPs compensation (or employment) is tied to their patient satisfaction.  And, we’ve argued time and time again that patient satisfaction has nothing to do with high-quality care, and that it’s insulting to degrade medical practice to customer service.

Now, this prospective cohort study of 36,428 patients from Archives demonstrates an association between patient satisfaction with their primary care physician and worse health outcomes.  They used the “Consumer Assessment of Health Plans Survey”, which included four items of interest to the authors: whether the physician listened carefully, explained things well, showed respect, and spent enough time with the patient.  There was also a fifth overall item of general health care rating for all their physician visits from the past year.
For a huge data set with a lot of granularity, the authors, unfortunately, don’t report the unadjusted mortality – which seems like it would be appropriate, when the major selling point is that mortality difference.  But, in any event, a few of the interesting adjusted associations:
 – Black race was more likely to be satisfied with their physicians. (1.17)
 – College graduates were less likely to be satisfied with their physicians. (0.78)
 – Public insurance was more likely to be satisfied with their physicians. (1.14)
 – Those in poor health were more likely to be satisfied with their physicians. (1.33)
That last item – the poor health – could potentially explain all the mortality difference.  They report unadjusted percentages for the rest of their measures, in addition to the adjusted OR, and then their main results come out: more satisfied patients are less likely to show up in the ED, more likely to be admitted, consumed slightly more healthcare dollars, and had slightly more prescription drug expenditures.  And, then, finally, the 1.26 increased hazard ratio for mortality.  Interestingly enough, when patients who have self-reported poor health and more than three chronic diseases are removed, the hazard ratio increases to 1.44.
So, satisfied patients in fairly good health, on whom more healthcare dollars are being expended, have significantly worse outcomes?  There must be more to this story than just patient satisfaction – which, unfortunately, seems to be all the lay press focuses on.
“The Cost of Satisfaction”

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”

Heart Failure, Informatics, and The Future

Studies like these are a window into the future of medicine – electronic health records beget clinician decision-support tools that allow highly complex risk-stratification tools to guide clinical practice.  Tools like NEXUS will wither on the vine as oversimplifications of complex clinical decisions – oversimplifications that were needed in a pre-EHR era where decision instruments needed to be memorized.

This study is a prospective observational validation of the “Acute Heart Failure Index” rule – derived in Pittsburgh, applied at Columbia.  The AHFI branch points for risk stratification are…best described below, in this extraordinarily complex flow diagram:

Essentially, the research assistants in the ED applied an electronic version of this tool to all patients given by the Emergency Physician a diagnosis of decompensated heart failure – and then followed them for the primary outcome(s) of death or readmission within 30 days.  In the end, in their small sample size, they find 10% of their low-risk population meets the combined endpoint, while 30.2% of their high-risk population meets their combined endpoint.  Neither group had a very high mortality – most of the difference between groups comes from re-admissions within 30 days.

So, what makes this study important isn’t the AHFI, or that it is reasonable to suggest further research might validate this rule as an aid to clinical decision-making – it’s the progression forwards of using CDS in EHR to synthesize complex medical data into potentially meaningful clinical guidance.

“Validating the acute heart failure index for patients presenting to the emergency department with decompensated heart failure”
http://www.ncbi.nlm.nih.gov/pubmed/22158534

Just Do It – Lytics for STEMI

PCI is fabulous – but only if you get them to the balloon in 90 minutes or less – otherwise, we should be giving thrombolytics for STEMI.  Unlike stroke, and even though many of these studies are manufacturer-supported, we have literally hundreds of thousands of patients randomized to tenecteplase, alteplase, streptokinase, etc. in combination with every different antiplatelet agent under the sun.  I still don’t know whether prasugrel and lytics go together, but I’m sure we’ll have GUSTO-10,000 soon enough.

Why do I bring this up?  Because it turns out we’re terrible at transferring patients to PCI-capable centers fast enough.  This is a retrospective, observational study of CMS OP-3, the door-in, door-out quality measure for STEMI patients receiving transfer.  A grand total of 9.7% patients in this review of 13,776 patient encounters met the quality standard of transfer within 30 minutes.

If you agree with the literature that says a DIDO time >30 minutes is associated with a 56% increased odds for in-hospital mortality, this could be important.

Lytics.  Just do it.

In fact, depending on the recency of symptoms, the location of the infarct, and whether we’re off-hours for cath lab activation, I’ll give full-dose lytics on arrival while awaiting cath lab transport.  Your mileage may vary, depending on your cardiology team.

“National Performance on Door-In to Door-Out Time Among Patients Transferred for Primary Percutaneous Coronary Intervention”
www.ncbi.nlm.nih.gov/pubmed/22123793

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”
http://www.ncbi.nlm.nih.gov/pubmed/22033993

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”
www.ncbi.nlm.nih.gov/pubmed/21908072

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”
http://stroke.ahajournals.org/content/42/11/3226.short