ED Push - August 2015 First Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Hospital Staff Often Overestimate Emergency Stroke Care Performance
DURHAM, NC – When it comes to speedy delivery of clotbusters to stroke patients, many emergency departments aren’t doing as well as they think.
That’s according to a new study, published recently in the Journal of the American Heart Association, which finds that hospitals frequently overestimate their efficiency in initiating tissue plasminogen activator (tPA).
The study team, led by current and former Duke University researchers, surveyed emergency medical staff in 141 hospitals treating 48,201 stroke patients in 2009 and 2010. Hospital staff survey responses were compared with actual data on patients, including the onset of their stroke symptoms; hospital arrival time; treatments, initiation of tPA; and complications from the drug.
Based on that, hospitals were categorized as high-, middle- or low-performing based on the percentage of time they appropriately administered tPA. Included in the assessment was "door-to-needle" time, which is how quickly the clotbusting drug is administered from the time the patient arrives at the hospital; guidelines recommend that occur within 60 minutes.
Study results indicate that only 29% of hospital staff accurately identified door-to-needle performance. In fact, 42% of middle-performing hospitals and 85% of low-performing hospitals overestimated their ability to quickly administer the drug. Furthermore, nearly 20% of low-performing hospitals believed their door-to-needle time was above the national average.
“Hospitals often overestimate their ability to deliver timely tPA to treated patients,” study authors point out. “Our findings indicate the need to routinely provide comparative provider performance rates as a key step to improving the quality of acute stroke care.”
The exaggeration was not without consequence: Hospitals that overestimated their performance tended to have lower volumes of tPA administration, smaller percentages of eligible patients receiving tPA and smaller percentages of door-to-needle time of 60 minutes or less minutes among treated patients.
The surveyed hospitals all participated in the American Heart Association's Get With the Guidelines-Stroke national quality improvement program designed to ensure consistency in timely stroke care. Stroke patient volume affected the disparity between hospital perception and performance, but hospital size or region did not appear to be a major factor.
"Institutions at any performance level could benefit from making protocol changes that would better align performance with perception," lead author Cheryl Lin, MD, a former researcher at Duke Clinical Research Institute in Durham, NC, advised in an AHA press release. "This would have a significant impact on the quality of stroke care delivered across the U.S."
Survey Superior to Blood Test for Alcohol-related Trauma Prediction
MAYWOOD, IL – With as many as half of all trauma patients presenting with alcohol in their bloodstream at the time of admission, you can expect to see at least 10% returning to your emergency department within a year.
The question is how to identify those at greatest risk of future drinking-related trauma for intervention. A study published recently in The Journal of the American Osteopathic Association offers a suggestion: a 10-point questionnaire is more effective than the standard blood alcohol content test.
The Alcohol Use Disorders Identification Test (AUDIT), which assesses alcohol consumption, drinking behaviors, and alcohol-related problems, was developed by the World Health Organization to address difficulties in identifying at-risk drinking behavior.
In a study, Loyola University Medical Center researchers found the 10-point questionnaire to be 20% more effective than simply measuring blood alcohol level in detecting patients with at-risk drinking behaviors likely to result in future ED visits.
"Given the interactions between alcohol and trauma, screening and intervention for at-risk drinking behavior are important components of injury prevention and public health,” said lead researcher Timothy Plackett, DO. “Previous studies have shown that brief interventions with these patients can lead to a 50% reduction in future trauma visits.”
For the retrospective cohort study, the study team reviewed 222 records, including all patients 18 and older admitted to Loyola University Medical Center's level I trauma center between May 2013 and June 2014. Patients' records were included if both a blood-alcohol level result and an AUDIT score were on file, with a blood-alcohol level greater than 0 g/dL and an AUDIT score equal to or above eight considered positive for at-risk drinking.
Among records of 750 predominantly male (80%) patients admitted for trauma, 30% contained data on both blood-alcohol level and AUDIT score. The most common injury for the patients, who had a median age of about 40, was blunt trauma, diagnosed in 80%.
Of the group, 44% had a positive blood-alcohol level, 35% had a positive AUDIT score, and 24% met National Institute on Alcohol Abuse and Alcoholism criteria for at-risk drinking. While the sensitivity and specificity of having a positive blood-alcohol level identify at-risk drinking were 61% and 62%, respectively, the sensitivity and specificity of having a positive AUDIT score identify at-risk drinking were 83% and 81%, respectively, according to study results.
“As a stand-alone indicator of at-risk drinking behavior in trauma patients, the AUDIT score was shown to be superior to blood alcohol level,” the authors report. “The utility of obtaining routine blood alcohol levels in trauma patients as a screening tool for at-risk drinking should be reexamined.”
Yet, the AUDIT assessment added little time or cost to care of the trauma injured patient.
"The potential cost savings from reducing trauma visits could amount to more than $1.8 billion a year, making screening and intervention for at-risk drinking one of the single most cost-effective preventative healthcare measures," said Mark Mitchell, DO, president of the American College of Osteopathic Emergency Medicine.
Biomarker Shown Effective in ED Diagnoses of Pneumonia, Heart Failure
BOSTON – “Doctor, I can’t catch my breath” is a common complaint in emergency departments. The challenge is determining the cause of the dyspnea.
As a result, many EDs are turning to biomarkers to improve diagnostic accuracy and aid with prognostication in patients with breathing complaints.
A study published recently in the American Journal of Medicine examined the clinical utility of serum procalcitonin (PCT) for the diagnosis of pneumonia in patients presenting to the ED with dyspnea. Researchers from Massachusetts General Hospital and Harvard Medical School also sought, as a secondary objective, to evaluate the prognostic value of PCT for death to a single year.
Overall, they found the biomarker a useful tool.
“In emergency department patients with acute dyspnea,” study authors write. “PCT is an accurate diagnostic marker for pneumonia, and adds independent prognostic information for 1-year mortality.”
For the study, researchers pooled the patient populations of two prospective cohorts that previously enrolled patients presenting with dyspnea to two urban EDs, focusing on 453 patients having serum samples available for biomarker analysis. They reviewed clinician certainty for the diagnosis of acutely decompensated heart failure as well as discrimination, calibration, and net reclassification improvement for the diagnosis of pneumonia, taking into account any fatal outcomes.
Results showed that pneumonia alone was diagnosed in 6.6% of patients, heart failure without pneumonia in 47% and both diagnoses in 6.6%. PCT concentrations were higher in subjects with pneumonia.
“Across all levels of clinician-based estimates of heart failure, PCT was sensitive and specific; notably, in patients judged with diagnostic uncertainty (n = 70), a PCT value of 0.10 ng/mL had the optimal balance of sensitivity and specificity (80% and 77%, respectively) for pneumonia,” study authors note.
Overall, adding PCT results to variables predictive of pneumonia resulted in a net reclassification improvement of 0.54 for both up- and down-reclassifying events. In adjusted analyses, elevated PCT was a predictor of one-year mortality, especially when elevated in conjunction with natriuretic peptides.
Most ED Patients With Delirium Unrecognized; Study Seeks Solutions
INDIANAPOLIS – With time pressure and managing multiple patients, emergency clinicians often fail to recognize delirium in older adults visiting their facilities.
In fact, about two-thirds of the cases of the sudden and potentially lethal change in mental status go undiagnosed in EDs, although, within six months, patients with undetected delirium who were discharged from the ED have significantly higher mortality rates than those whose delirium was recognized, according to a study published online by Dementia: The International Journal of Social Research and Practice.
To identify the barriers to detecting delirium during emergency care, researchers from the Indiana University Center for Aging Research and the Regenstrief Institute conducted focus groups with ED staff.
"Delirium is a serious condition that is too often missed in the ambulance and emergency department and we need to improve its detection," said lead author Michael LaMantia, MD, MPH, an Indiana University Center for Aging Research scientist, Regenstrief Institute investigator and assistant professor of medicine at IU School of Medicine, who added, “Unrecognized delirium presents a major health challenge to older adults and an increased burden on caregivers and the healthcare system."
In focus groups convened by the researchers, emergency physicians, ED nurses, and emergency medical service personnel suggested that delirium recognition is hampered by unawareness of the baseline cognitive state of the patient, particularly among those with pre-existing cognitive impairment such as Alzheimer's disease.
That’s why, for example, ED staffers were more likely to suspect delirium in older adults when patients exhibited agitation, not those who were withdrawn. Focus group participants, drawn from Eskenazi Health and IU Health, expressed the need for a delirium screening test that could be rapidly administered.
"We're comfortable with obvious delirium,” said one physician participating in a focus group. “We're all petrified, and we, at least I know my own limitations is that I guarantee you I'm missing patients who have it. And so what would make me comfortable is that when you come back to me and you said, hey we've got a 30-second test that is pretty good at screening for delirium."
Other physicians said that any ED dementia screening tool needs to be "physician proof," simple to document, not open to interpretation, brief to administer, and "better than our judgment."
Nurses also said they were often uncomfortable dealing with patients with delirium, especially when the ED was busy.
"Clear steps should be taken to improve delirium care in the emergency department including the development of mechanisms by which the medical staff can easily learn about the patient's mental status from family or friends, the adoption of a systematized approach to recognizing delirium, and the institution of protocols to treat the condition when it's identified," LaMantia said. "The efforts of emergency providers, geriatricians, brain scientists, and implementation experts will be needed to further develop and test these responses to this challenging clinical condition."
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