ED Push - January 2015 First Issue
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CDC: Give Immediate Antivirals to High Risk Patients with Flu Symptoms
ATLANTA – When high-risk patients present to your emergency department with flu-like symptoms, the CDC says there’s no need to hesitate on the course of treatment.
“While doctors may prescribe antiviral drugs for non-high risk patients with flu, all high risk patients with suspected influenza should be receiving antiviral drugs,” the CDC emphasizes.
Patients considered to be at high risk of serious flu complications include those 65 and older, children younger than 5 years (and especially those younger than 2 years), pregnant women and any person with a variety of health conditions such as asthma, neurological and neurodevelopment conditions, chronic lung disease, heart disease, blood disorders, diabetes and other endocrine disorders, kidney disorders, liver disorders, metabolic disorders, weakened immune systems, morbid obesity as well as patients younger than 19 on long-term aspirin therapy.
In addition to oseltamivir (Tamiflu) and zanamivir (Relenza), a new intravenous formulation, peramivir (Rapivab) has been approved by the FDA for use this season in patients 18 and older.
While the drugs work best when started within two days of symptom onset, patients with high-risk conditions can benefit even when antiviral treatment is initiated later, the CDC points out.
EDs have been inundated with flu patients for the last six weeks, especially in the South but increasingly in the Midwest, according to public health officials. The Northeast and West have yet to feel the full force of the flu season, however, and the CDC suggests the nation may just be reaching the midpoint.
Currently, medical visits for influenza-like illness (ILI) have been elevated for six consecutive weeks. Over the past 13 flu seasons, ILI visits remain up for an average of 13 weeks. In fact, those visits now are even with the peak of the 2012-13 season, the last time H3N2 viruses predominated.
The most recent weekly flu report notes that more than 40 states are experiencing either high or widespread flu activity, mostly resulting from circulation of drifted H3N2 viruses. Similar to past H3N2-predominant seasons, the nation also is experiencing relatively higher flu hospitalization rates. For week 52, overall flu-related hospitalizations were 12.6 per 100,000 people, comparable to the 13.3 per 100,000 overall hospitalization rate seen during the same week of the 2012-13 season, but higher than the 8.9 per 100,000 rate observed during week 52 last season, which was H1N1-predominant.
Most of the H3N2 viruses circulating this year are drifted from the H3N2 virus in the annual vaccine, according to the CDC. While recent studies indicate that flu vaccine reduces the risk of medical visits due to flu by approximately 60% among the overall population when the vaccine is a good match, effectiveness is lowered by drifting. For example, during the 2007-08 flu season, when drifted H3N2 viruses circulated, vaccine effectiveness estimates against H3N2 were 43%.
Vaccine effectiveness estimates are expected to be available in mid-January for the current season.
Despite the lower effectiveness, the CDC continues to recommend flu vaccination for everyone older than 6 months old who has not received one. The recommendation includes patients who have already gotten the flu this season because flu vaccines protect against three or four different viruses, and the possibly remains of a second wave of flu activity, which often is caused by an influenza B virus.
Fingertip Blood Sensor Can Save Valuable Time in Trauma Assessment
TUCSON, AZ – A tool now used to check for anemia in patients visiting physician offices could be employed in EDs to speed up medical decision-making for critically injured trauma patients, according to a new study.
For the research, published recently in the Journal of the American College of Surgeons, the use of the Spot check Pronto-7® Pulse CO-oximeter was evaluated in 525 critically injured patients.
Background in the study, led by trauma surgeons from the University of Arizona, suggests that the investigation was the largest ever for such a device.
The device is manufactured by Masimo of Irvine Park, CA, which did not provide any funding, devices or compensation for the study, according to study authors.
The current process is to send the sample to a clinical laboratory for analysis to get a reading on the hemoglobin count, which can take 10 minutes or longer, according to lead author Bellal Joseph, MD, FACS.
The spot check device, however, uses a fingertip sensor to provide a reading within 40 seconds to help determine the presence of internal bleeding.
“This device was initially intended for outpatient medical offices to obtain readings of people who were anemic, but the ability to get hemoglobin readings with a device that one places on the finger intrigued us,” Joseph said. “It can help make a medical decision very quickly about where this patient needs to go — to the operating room or intensive-care unit — without waiting for laboratory results. It gives us immediate information that we otherwise could not get.”
In the study, 450 (86%) of the 525 patients underwent the Spot check measurements successfully. Mean age of the patients was 41, 74% were male and the mean Injury Severity Score was 21. Hgb less than or equal to 8 mg/dL was detected in 38% of the patients at presentation.
With three Spot check measurements associated with an invasive blood draw, results showed a strong correlation between the two, according to the results. Mean invasive Hgb was 11.5 ± 4.36 g/dL, mean spot check Hgb was 11.1 ± 3.60 g/dL, and mean difference was 0.3 ± 1.3 g/dL.
Study authors note that spot check Hgb values had strong correlation with invasive Hgb measurements with 76% accuracy and 95.4% sensitivity.
In a few cases, sensor readings were disrupted for reasons such as nail polish on the patient’s fingernails or dust or soot on the patient’s fingers. There also were instances where the sensor did not fit the patient’s finger; although the device comes in three sizes, the research team only had access to one size.
Overall, the fingertip sensor showed some significant advantages over traditional intravenous blood draws, Joseph said.
“Sometimes patients are so severely injured when they come in, we have to place a special line in their neck or more central part of body to get blood,” he said. “It does not always have to be the extreme patient, but even the patient who seems fine may have internal bleeding.”
He said the device would be especially useful in the very young and very old, especially because of the difficulty in finding a good vein in elderly patients.
Next steps in evaluating trauma use of the device, according to Joseph, are:
- Implementing a protocol for nurses to use it,
- Extracting readings into the patient’s electronic medical records.
- Finding a way to use the device to continually monitor blood levels in patients with severe organ injuries at set time intervals
Joseph noted that Masimo will supply devices for a second study to learn more about how the monitor can be used in the trauma bay.
Improvement Initiative Speeds Antibiotics to Children with Central Lines
CHAPEL HILL, NC – Pediatric patients who have central lines and present to the ED with fever require rapid antibiotic administration, but that doesn’t always happen as quickly as it should.
To remedy that, University of North Carolina, Chapel Hill, researchers conducted an ED improvement initiative with the goal of delivering antibiotics to 90% of those patients within an hour while also minimizing process variation.
According to a report published online recently by the journal Pediatrics, the initiative more than met the goal, sustaining that timetable for at least 24 months. In addition, it eliminated race-based discrepancies in care.
In the academic ED, a multidisciplinary team was assembled, identified contributing factors to the care delivery problem were identified, and key drivers and intervention steps were determined. When the changes were implemented, the researchers used strategies to engage ED staff and promote sustainability.
Outcomes, analyzed by using a time series design with baseline data and continuous postintervention monitoring, included percentage of patients receiving antibiotics within 60 minutes, time to antibiotic administration, and accuracy for triage acuity and chief complaint.
The intervention began after an 8-month baseline period where 63% of patients received antibiotics within 60 minutes of arrival with a mean time to antibiotics of 65 minutes. After multiple Plan-Do-Study-Act (PDSA) cycles were used to improve patient identification and initial management processes, the percentage of patients receiving antibiotics within 60 minutes of arrival was increased to 99% (297 of 301). Mean time to antibiotic administration, meanwhile decreased to 30 minutes.
After two years, the ED still met the goals.
Interestingly, the intervention did more than originally planned. After subanalysis identified a racial discrepancy, with African-American patients experiencing significantly longer delays of an average of 95 minutes compared to patients of other races who received antibiotics within 61 minutes, the initiative eliminated that discrepancy also.
Need to Know How Busy Your ED Will Be? Google It.
STOCKHOLM, SWEDEN – Need to know how many patients will show up at your ED tomorrow? In the near future, you might just be able to ask Google and other search engines.
That’s according to a study finding that the correlation between Internet searches on a regional medical website and next-day visits to regional emergency departments was “significant.” The report was published online recently in the Annals of Emergency Medicine.
“Website visits may be used to predict ER visits for a geographic region as well as for individual hospitals,” said lead study author Andreas Ekstrom, MD, of Karolinska Institutet in Stockholm. “Looking forward, we might be able to create a model to predict emergency department visits that would enable better matching of personnel scheduling to ER volumes.”
For the study, the researchers used Google Analytics, tallying and graphing Internet searches of the Stockholm Health Care Guide (SHCG), a regional medical website, over a 1-year period. ED visits were then compared over the same time period.
The study included all types of ED visits – such as adult and pediatric – and used the period of Aug. 13, 2011, to Aug. 12, 2012, as a training set for the model. The hourly variation of visits was analyzed for both website and the ED visits to determine the interval of hours to be used for the prediction, and the model was then validated with mean absolute percentage error for Aug. 13, 2012, to Oct. 31, 2012.
Results indicate that online visits to the SHCG between 6 p.m. and midnight were significantly correlated to the number of ED visits the next day.
Overall, the error rate when individual hospitals ED visits were based on Internet searches ranged from 5.2% to 13.1%.
The study found that ED visits typically were highest on Mondays and lowest during weekends, with peak visits occurring at noon and then slowly decreasing during the rest of the day. With the lowest number of ED visits three days around Christmas, New Year and the midsummer holidays, the fewest number of Internet searches occurred during the same time period.
“Website visits may be used in this fashion to predict attendance to the ED,” the authors conclude. “The model works both for the entire region and for individual hospitals. The possibility of using Internet data to predict ED visits is promising.”
“For this type of information to be useful, it is important that we be able to predict emergency department visits further into the future than the next day,” Ekstrom added. “This may be possible by further investigating the correlation between website statistics and ER visits. This has the potential benefit of reflecting ongoing behavioral trends, which may allow us to adapt to sudden changes in patient behavior when predicting ER visits."
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