December 2013 – Page 2 – Emergency Medicine Literature of Note

Sepsis, NHAMCS, and Non-Truths

“… our results provide a worrisome view of the quality of care of septic patients in U.S. EDs.”

Crikey.

This is serious business. Tell me more.

“Our data suggest that many emergency department patients (31%) with sepsis do not receive antibiotics until they arrive on the inpatient unit.”

This is somewhat concerning data. Of course, some patients can have sepsis from viremia, and would not warrant antibiotics – but, I think most admitted patients with SIRS and a suspected infectious source ought to receive treatment.

But, unfortunately, for this study, the question is less the quality of ED care, and more the quality of the data source. The National Hospital Ambulatory Medical Care Survey is a lovely data set, whose quality is only increasing as coding and structured data become more prevalent – but a retrospective analysis of these data is not appropriate substrate to make sweeping generalizations regarding the care in the Emergency Department.

From the ~400 Emergency Departments providing yearly data to NHAMCS, 0.32% of patients met their definition of sepsis. That meant these data reflect a sample of 1,141 patients, and the admitted limitation of “studies relying on NHAMCS data are vulnerable to errors of omission in data collection.” These authors lack information regarding previously administered antibiotics from transferred patients, and admit some patients – those spending <1 hour in the ED – may simply have left the ED before antibiotic administration could be completed.

Quite simply, it’s (mostly) garbage in and (mostly) garbage out.

The authors also attempt an assessment of antibiotic appropriateness from this retrospective chart abstraction. It is so egregiously flawed it doesn’t even warrant comment.

“Sepsis Visits and Antibiotic Utilization in U.S. Emergency Departments”
http://www.ncbi.nlm.nih.gov/pubmed/24201179

Total Fever Illiteracy

If you weren’t already aware, the American Academy of Pediatrics recently published a policy statement concerning the use of antipyretics to reduce temperature in a febrile child.

Don’t do it.

The available evidence is treatment of fever may ultimately attenuate the body’s natural immune defenses, while parents inadvertently place their children at risk by using inappropriate dosages. The only goal of antipyretic use is to improve overall patient comfort.

And, as this study shows, we have a long, long way to go in educating our patients.

This is a survey of 100 patients – 54 from a private clinic and 46 from a county clinic – and, within the bounds of the small sample, there is essentially no difference in the perception of fever. Nearly 75% failed to correctly identify the temperature range constituting fever (>38°C). 93% thought high fever results in brain damage. 89% would give antipyretics to a comfortable child with temperature >38°C, and 86% would go ahead and schedule a clinic visit. Equally surprising (or not), 59% would dose a comfortable child with temperature 37.4-37.8°C with antipyretics, and 38% would schedule a clinic visit.

Given the volume of ambulatory visits for fever – both in the Emergency Department and community Pediatrics – it would seem continued education regarding “fever phobia” has the potential for significant cost savings.

Brain damage, by the way, is not usually a concern until 42°C.

“Fever Literacy and Fever Phobia”
http://www.ncbi.nlm.nih.gov/pubmed/23349363

Stepping Up to Choosing Wisely

ACEP recently published their own “Choosing Wisely” campaign contribution – a list of five changes to Emergency Medicine practice that ought be encouraged in the interests of increasing cost-effective care. While most would agree the ACEP version is reasonable, I think many clinicians hoped for something a little more earth-shattering.

Something like the Pediatric Hospital Medicine list for Choosing Wisely.

These authors specifically looked at the top 10 inpatient diagnoses in terms of volume and aggregate costs, and specifically evaluated components of treatment as candidates for recommendations. And, even speaking as someone who makes an effort to minimize testing – I find these recommendations take an impressive step in terms of aggressive reduction in resource utilization.

The highlights:
Do not order chest radiographs in children with asthma or bronchiolitis.
Do not use bronchodilators in children with bronchiolitis.
Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection.

How often do you get radiographs in patients with respiratory disease – that get discharged? How about admitted? The authors estimate 60% of admitted patients receive radiographs, with fewer than 2% affecting clinical management.

Or, routine bronchodilator therapy – which, frankly, is ordered for a lot of children simply due to a sense we ought to do something. Both beta-agonist and racemic epinephrine fall under this recommendation, as they’ve not been shown to confer any reliable, clinically meaningful, patient-oriented outcome in bronchiolitis.

Finally – corticosteroids. Young children, even with albuterol-responsive wheezing, showed no benefit when corticosteroids were added. These are not harmless interventions, particularly for growing infants, and seems to pre-dispose some folks to subsequent readmission.

With pediatric respiratory season on the horizon, I challenge all of you to use this document as a tool share with colleagues and consultants to decrease unnecessary testing and therapy.

“Choosing Wisely in Pediatric Hospital Medicine: Five Opportunities for Improved Healthcare Value”
http://www.ncbi.nlm.nih.gov/pubmed/23955837

Man vs Machine: A CPR Battle to the…

A guest post by Rory Spiegel (@CaptainBasilEM) who blogs on nihilism and the art of doing nothing at emnerd.com.

Presenting the LUCAS 2.0, the latest and greatest in CPR technology! The LUCAS device “provides the same quality for all patients and over time, independent of transport conditions, rescuer fatigue, or variability in the experience level of the caregiver.” Or at least that is what the manufacturer, Physio-Control Inc, will have you believe.

High quality CPR and early defibrillation have been the cornerstones of cardiac arrest management since the AHA published their “Chain of Survival”. Reducing the time off the chest is of utmost importance in the current CPR mantra. So a machine that not only performs consistent high quality CPR, but delivers countershocks without interrupting compressions was sure to show benefit in patient oriented outcomes. What follows is a Paul Bunyan-like contest of man against machine. One in which the makers of the LUCAS device strived to prove modern technology’s superiority over good old fashion manpower. In a delightful twist on the original tale the fancy new mechanical CPR device was found to be no better than traditional CPR.

The trial published in JAMA in November 2013, randomized 2,589 subjects to either traditional CPR following the 2005 European Resuscitation Council guidelines or a mechanical compressions protocol. Patients in the mechanical CPR group received traditional compressions until the device could be deployed, at which point compressions were continued mechanically. Ninety seconds after deployment the device delivered a countershock regardless of the initial rhythm. After which the rhythm was checked every 3-minutes and, if appropriate, a shock was delivered after a 90-second delay.

Despite the obvious advantages the LUCAS device provides, no difference was found in survival at 4-hours, ICU discharge, 1-month, or 6-months. The authors claim victory in a single positive endpoint that reached significance. The number of patients with a CPC score of 1 at 1-month was 2.6% in the traditional CPR vs 4.2% in the mechanical CPR group (p-value of 0.04). This is, of course, just post-hoc dredging of innumerable secondary outcomes, and nothing more than statistical noise. To the authors’ credit, they do not revisit this positive finding.

Despite their claims that the LUCAS device would free up rescuers to do other life sustaining actions, patients in the manual CPR group were defibrillated sooner, intubated faster, transported earlier, and arrived at the hospital in a swifter fashion than those in the mechanical CPR group.

The authors conclude “CPR with this mechanical device using the presented algorithm can be delivered without major complications but did not result in improved outcomes compared with manual chest compressions.” Given that there were only 7 major adverse events in the mechanical CPR group vs 3 in the tradition CPR group this does seem to be the case. Though I would caution, with the low incidence of adverse events, this trial was not powered to truly assess safety of the mechanical delivered CPR.

“Mechanical Chest Compressions and Simultaneous Defibrillation vs Conventional Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest: The LINC Randomized Trial” www.ncbi.nlm.nih.gov/pubmed/24240611

Man vs Machine: A CPR Battle to the…

A guest post by Rory Spiegel (@CaptainBasilEM) who blogs on nihilism and the art of doing nothing at emnerd.com.

It’s Silly Season on Flu

We still don’t know whether neuraminidase inhibitors (e.g., oseltamivir [Tamiflu]) are helpful. Roche has prevented access to trial data until just this year, and the results of independent review are still pending. However, that has not stopped plenty of smart, well-meaning folks from taking their claims at face-value and using NAIs to treat influenza.

This is a retrospective registry review of 3 years of children admitted to California ICUs with a laboratory-confirmed diagnosis of influenza. 850 children were identified in the registry, and 784 children had clinical information available for analysis. Of these, 653 received NAIs and 38 (6%) died. Of the remaining 131 untreated patients, 11 (8%) died. Using a multivariate model adjusting for univariate predictors of death, NAI therapy was associated with decreased mortality (OR = 0.36, 95% CI 0.16-0.84).

But, while registry reporting was mandatory for deaths due to influenza, it was only optional for ICU hospitalization – leading to an unknown selection bias in their study cohort. There were also 23 deaths reported prior to hospitalization for whom no data is available. Most patients in the study treated with NAIs were H1N1, while the small remainder comes from the post-pandemic period with a mix of H1N1, other influenza As, and influenza B – and therefore may not be generalizable to a non-pandemic influenza season. A standardized abstraction form was used, but the complete baseline demographics collected are not included in the article; most patients included had significant respiratory comorbidities, and these chronically ill children were far more likely to die regardless of treatment. In summary, with a small sample size, likely missing data from abstraction, and selection bias underlying their cohort, the multivariate analysis upon which they based their final conclusion is junk.

In contrast to the editor’s summary “What this study adds”, which concludes special emphasis on treatment with NAIs may improve survival, I would revise it to say: “No additional practice-changing evidence”.

Now, I can’t say I’m opposed to treatment of hospitalized influenza patients with NAIs – least of all, those in the ICU. While outpatient therapy with NAIs for influenza is almost certainly a waste of money, in severe disease, the cost relative to the entire expenditure shrinks rapidly – the threshold for cost-effectiveness is met even if one patient out of a hundred has a one day reduction in ICU length-of-stay. But, it’s inappropriate to over-sell the meaning in this data to suggest any certainty NAIs are helpful.

“Neuraminidase Inhibitors for Critically Ill Children With Influenza”
http://www.ncbi.nlm.nih.gov/pubmed/24276847

I’ve Got the [Wrong] Answer!

Most of us think we have fair insight into our own medical decision-making. When presented with a difficult case, I think most would presume to present a provisional diagnosis with a decreased level of confidence.

Apparently, nope.

This fascinating insight into decision-making comes from a set of clinical case vignettes distributed to physician volunteers. 118 physicians were recruited via e-mail to complete four structured case presentations – two “easy”, two “difficult”. Physicians were not specifically notified regarding the variable difficulty of the cases involved. They were provided first the history, then the exam, followed by results of general and specific testing, if requested. During each stage of the process, physicians were asked to provide preliminary diagnoses and their level of confidence.

For the two easy cases, the mean confidence level of respondents was a little over 70%. And, final diagnostic accuracy was a little under 50%. For the difficult cases, the mean confidence level of respondents was about 65%. And diagnostic accuracy was … 5%. Almost as confident, almost never right.

Physician characteristics provided few insights regarding behavior, confidence, and accuracy. Increasing years of experience were related to decreased testing and consultation requests – but, for the most part, the only insight: physicians are lacking in insight.

“Physicians’ Diagnostic Accuracy, Confidence, and Resource Requests”
http://www.ncbi.nlm.nih.gov/pubmed/23979070

Mostly Dead is All Dead – Neuro Outcomes in OHCA Without Prehospital ROSC

A guest post by Anand Swaminathan (@EMSwami) of EM Lyceum and Essentials of EM fame.

Over the last two weeks there has been a lot of buzz around the NEJM study on targeted temperature management in out of hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC). This blog has been no exception. This article we’re going to discuss here addresses the care of a very different population: the patient with OHCA without ROSC in the field.

Over four years, 398,121 adults with OHCA and no ROSC in the field were prospectively entered into a database. The overall survival was dismal (1.89%) with even fewer patients having a good neurologic outcome (0.49%). Neurologic outcome was defined using the Cerebral Performance Category (CPC) scale with a CPC 1 or 2 as a good neurological outcome. Using logistic regression, the authors identified nine factors that were associated with a CPC 1 or 2 outcomes. The authors further stated that there were four critical factors predictive of a good neurological outcome in these patients: initial non-asystole rhythm; age < 65 years, EMS witnessed arrest and hospital arrival time (from call) < 24 minutes. They further broke down the outcomes by type of non-asystolic rhythm:

There are a number of interesting findings in this study. If there’s no ROSC in the field, the chance of achieving good neurologic status is minimal. Survivors were 3-4 times more likely to have a poor neurologic outcome (i.e. severe cerebral disability, coma or brain death) than a good one (1.89% vs. 0.49%). The presence of the previously mentioned four factors was associated with a higher incidence of better outcomes. In particular, a presenting rhythm of ventricular fibrillation had an adjusted OR of 9.37 for a good outcome. Additionally, this study showed, as others have in the past, that epinephrine use increased the rate of ROSC but did not increase the rate of good neurological outcomes (see also Stiell 2004, Hagihara 2012).

How does this change what we do? We’ve all been working when EMS brings in an unwtinessed arrest patient that never had ROSC. The entire ED team mobilizes to care for this patient even though we know the potential for a good outcome is miniscule. This study provides preliminary information on which patients are more likely to have a good neurologic outcome. It should be the basis of further studies looking at protocols to stop resuscitation in the field and avoid transport to the hospital.

References

Goto Y, Maeda T, Nakatsu-Goto, Y. Neurological outcomes in patients transported to hospital without prehospital return of spontaneous circulation after cardiac arrest. Critical Care 2013; 17:R274 doi: 10.1186/cc13121 [Open Access]

Stiell IG et al. ACLS in OHCA. NEJM 2004; 351: 647-56.

Hagihara A et al. Prehospital Epinephrine Use and Survival Among Patients with OHCA. JAMA 2012; 307(11): 1161-68

Mostly Dead is All Dead – Neuro Outcomes in OHCA Without Prehospital ROSC

A guest post by Anand Swaminathan (@EMSwami) of EM Lyceum and Essentials of EM fame.

References

Stiell IG et al. ACLS in OHCA. NEJM 2004; 351: 647-56.

Hagihara A et al. Prehospital Epinephrine Use and Survival Among Patients with OHCA. JAMA 2012; 307(11): 1161-68

A Snapshot of Chest Pain Waste

The Lown Institute continues their conference today on avoidable care in the U.S., so this study is a lovely glimpse into one of the worst offenders in Emergency Medicine – chest pain.

Coming from the University of Pennsylvania, this is a retrospective review of patients 805 patients for whom an ED observation protocol of rapid rule-out and stress testing was performed. The supposed point of this article is to demonstrate the potential safety of stress testing after two sets of cardiac troponin 2-hours apart, and, in theory, they do demonstrate this. Of these 805 patients, 16 patients were diagnosed with acute myocardial infarction on index visit through this protocol – and within 30 days, 1 patient had AMI and 2 received revascularization.

The authors conclusion: “…serial troponins 2 hours apart followed by stress testing is safe and … rapid stress testing represents another option to expedite care of patients with potential ACS”.

789 of 805 patients received serial troponins and a negative stress test to identify a handful of higher than minimal risk folks. The 16 AMI diagnoses were based on 12 patients with negative troponins and positive stress tests, 1 patient with troponins that rose from <0.02 to 0.16 ng/mL and a negative stress test, and 3 patients with troponins rising from <0.02 to 0.06-0.09 ng/mL and positive stress tests. But, in order to dredge up these soft diagnoses of ACS, hundreds of thousands of dollars in financial damage were inflicted on the remaining cohort.

These authors feel rapid stress testing is an alternative to CTCA for preventing avoidable admissions. In the spirit of the Lown Institute, and of Rita Redberg’s NEJM editorial regarding CTCA, the true strategy for preventing an avoidable admission is simply to discharge the majority of these patients. A less than 2% yield for an expensive observational diagnostic strategy is far more grossly negligent a failure of medicine than an occasional missed minor MI. We can do nearly as well, for much less cost – but if only we continue to address our “zero-miss” cultural expectations surrounding diagnosis and treatment.

“Safety of a rapid diagnostic protocol with accelerated stress testing”
http://www.ncbi.nlm.nih.gov/pubmed/24211281