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ED Push - July 2015 First Issue

Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports

ED Management -
ED Legal Letter - Critical Care Alert

ED Clinicians Often Fooled by STIs Appearing to be UTIs

CLEVELAND – A woman presents at the emergency department with painful or difficult urination, frequency and urgency.

If you guessed urinary tract infection, you might be wrong but you certainly aren’t alone.

EDs misdiagnose urinary tract and sexually transmitted infections in women nearly half the time, according to a report published recently in the Journal of Clinical Microbiology. The study team, led by researchers from Case Western Reserve University, notes that symptoms and even urinalysis results can be similar between the two conditions.

"Less than half the women diagnosed with a urinary tract infection actually had one," said Michelle Hecker, MD, an assistant professor in the Department of Medicine, Division of Infectious Diseases, MetroHealth Medical Center at Case Western. "Sexually transmitted infections were missed in 37% of the women, many of whom were wrongly diagnosed with urinary tract infections."

She called for revaluation of ED diagnostic testing strategies after the study, which included records from 264 women aged 18-65 who were seen at the MetroHealth ED. Urine samples provided by the women were retrieved and tested for gonorrhea, chlamydia, and trichomonas even when the tests were not been ordered as part of routine care.

The study points out that overdiagnosis of UTI leads to unnecessary antibiotic use as well as underdiagnosis of sexually transmitted infection. During the two-month observational cohort study, 64% of the patients with a missed STI were diagnosed as having UTI.

"An abnormal UA [urinalysis] result, seen in 92% of our subjects, was a common finding, poorly predicted the presence of a positive urine culture, and may also have contributed to the overdiagnosis of UTI,” study authors point out.

Furthermore, nearly a fourth of the patients diagnosed as having UTIs had no related symptoms or urine culture. Of 21 women who received antibiotic therapy within a week after urine culture, representing 8% of the total, 10 had had negative urine cultures, and 12 failed to receive optimal antibiotics for their condition, according to the report.

Overall, 175 of the patients had been diagnosed as having a UTI, although 57% had no urine culture performed during routine care. Even though 60 of the women had one or more positive STI tests, 37% received no treatment for that within seven days of the ED visit, according to the report.

“In this population, empiric therapy for UTI without urine culture testing and over-diagnosis of UTI were common and associated with unnecessary antibiotic exposure and missed STI diagnoses,” the authors conclude. “Abnormal UAs were common and not predictive of positive urine cultures.”

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Blood Clot Retrieval Now Recommended for Specific Stroke Patients

CHAPEL HILL, NC – After all of the discussion, it’s now official: Key cardiovascular groups now recommend using a stent retrieval device to remove blood clots in certain stroke patients who have clots obstructing the large arteries supplying blood to the brain.

In the focused update published recently in the journal Stroke, the American Heart Association and American Stroke Association endorse that course of treatment in specific cases.

Intravenous delivery of the clot-busting medication tissue plasminogen activator (tPA) within a few hours after ischemic stroke symptoms appear still is advised as optimal initial treatment in most cases.

"What we've learned in the last eight months, from six new clinical trials, is that some people will benefit from additional treatment with a stent retrieval device if a clot continues to obstruct one of the big vessels after tPA is given," said lead author William J. Powers, MD, the H. Houston Merritt distinguished professor and chair of the department of neurology at the University of North Carolina at Chapel Hill.

Results from randomized clinical trials published since 2013, when the last treatment guidelines were issued, are analyzed in the update.

The complex clot-removal procedure involves puncturing an artery in the groin and threading a thin wire tube up into the brain until it reaches the blocked vessel in one of the large arteries. The clot is retrieved, then removed, as the tube is pulled out.

"This additional treatment is more difficult than tPA, which can be given by most doctors in the emergency room," Powers pointed out.

The procedure, which should be initiated within six hours of the onset of stroke, only can be performed in specialized facilities such as Comprehensive Stroke Centers or some Primary Stroke Centers, he added, so one challenge is getting patients to the right hospital in time.

According to the focused update recommends, the stent retriever should be used to remove clots only in adult stroke patients who:

  • have no significant disability prior to the current stroke
  • received tPA within 4.5 hours of symptom onset
  • have a clot blocking a large artery supplying blood to the brain
  • had an acute, severe stroke
  • have imaging showing more than half of the brain on the side of the stroke is not permanently damaged
  • can have the procedure start within six hours after symptom onset

Suggesting the benefits substantially outweigh the potential risks in patients meeting the criteria, the evidence backing the new recommendation received the highest rating.

The use of stent retrievers is indicated in preference to other mechanical thrombectomy devices, although the focused update notes that the use of mechanical thrombectomy devices other than stent retrievers may be reasonable in some circumstances, based on a physician's clinical judgment.


Pediatric Food Allergies No Longer Discriminate; Cases Are Up

CHICAGO – Forget your assumptions that food allergies primarily affect white children from middle-to-high income families.

A new study of Illinois emergency department visits for severe food allergy reactions found that children of all races and backgrounds now are affected, with cases jumping up an average of nearly 30% over a five year period. The report was published recently in Annals of Allergy, Asthma & Immunology.

In fact, Northwestern University researchers and colleagues point out that Hispanic children, who previously had the lowest reported cases of food allergies, had the biggest increase of emergency room and hospitalizations overall, with a 44% annual rise.

The study included discharge data from 1,893 ED visits for anaphylaxis at about 200 Illinois hospitals from 2008 to 2012.

"This study shows that severe food allergies are beginning to impact children of all races and income," said lead author Ruchi Gupta, MD, a professor of pediatrics at Northwestern University Feinberg School of Medicine and an attending physician at Ann & Robert H. Lurie Children's Hospital of Chicago. "This is no longer primarily a disease of children who are white and/or from middle-to-high income families. Nobody is immune to it."

In the past, studies indicated that children who were white or from higher-income families were most affected by food allergies, with Hispanic children and children from lower socioeconomic families having less of a problem, Gupta noted. He added that no one knows why food allergies have tended to vary by race, ethnicity and socioeconomic levels.

Overall, ED visits for anaphylaxis increased 29.1% – from 6.3 ED visits and hospital admissions per 100,000 children in 2008 to 17.2 ED department visits and hospital admissions in 2012. While visits were most frequent each year for Asian children, the annual percent increase in visits was greatest among Hispanic children.

At the same time, visits by African American children rose an average of 28.1% annually, with white children up 30.6%, according to the study. The most common allergies requiring emergency intervention were from tree nuts, peanuts and milk.

"Ensuring timely diagnosis by the physician and education about recognition and management of severe and potentially fatal reactions is critical," Gupta emphasized. "We need targeted education to all families and public entities including schools, camps and restaurants because anaphylaxis can happen anywhere and at any time."

An earlier study by Gupta found that food allergy is a growing public health concern in the United States and affects about 8% of children, with nearly 40% having a history of severe reactions that can lead to hospitalization or even death without immediate treatment.


ED Prescribing for Elderly Improved in Team-Based VA Program

ATLANTA – In a crowded and fast-paced emergency department, who has time to look up which medications are optimal for elderly patients?

That was one of the assumptions in a new study conducted by Department of Veterans Affairs (VA) researchers. Yet, a study team lead by researchers from Emory University and the Atlanta VA Medical Center found that ED prescribing practices can be improved by use of a team including clinical pharmacists, emergency physicians, geriatricians, nurses and clinical applications coordinators. The report was published recently in the Journal of the American Geriatrics Society.

The study, Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the ED (EQUiPPED), is an ongoing multicomponent, interdisciplinary quality improvement initiative in eight VA EDs. The goal is to decrease the use of potentially inappropriate medications (PIMs), defined by the American Geriatrics Society Beers criteria, in veterans aged 65 and older.

Informatics-based clinical decision support with electronic medical record-embedded geriatric pharmacy order sets and links to online geriatric content as well as provider education, including academic detailing, audit and feedback, and peer benchmarking all were used to remedy the problem.

ED clinical staff attended a November 2012 geriatric pharmacology lecture, then reviewed the 2012 Beers Criteria Update two months later. Reminder cards listing the top five most-frequently prescribed PIMs were placed at ED computer stations in May 2013.

Perhaps most importantly, the study team put together outpatient pharmacy order sets with preferred medications for the elderly, categorized by common discharge diagnoses. ED prescribers were able to see the specialized sets when they viewed the original order sets in the electronic medical record.

“Dose adjustments for renal impairment, point-of-prescribing education regarding medications to avoid, and links to synthesized geriatric content were embedded within the order sets,” study authors explain. “The order entry process was streamlined with prepopulated fields including: ‘days supply,’ ‘number of pills,’ and method for prescription pick-up.”

Before the targeted intervention, “the average monthly proportion of PIMs prescribed was 9.4 ± 1.5%. This declined to 4.6 ± 1.0% after the initiation of the EQUiPPED interventions,” the authors note.

The largest decrease was documented with muscle relaxants but there also were declines in prescriptions for chronic NSAIDs, and promethazine, according to the study results. The authors note the PIMs reduction was sustained for 12 months, “suggesting a culture change with respect to prescribing patterns for older adults discharged from the ED.”


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