ED Push - November 2015 First Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
No Increased Mortality for Sepsis Patients Stabilized in ED
GEORGETOWN, TX – Severe sepsis patients stabilized in the emergency department instead of immediately triaged to a hospital’s intensive care unit had no increased risk of mortality, according to a new study.
Those findings were based on a retrospective chart review by a research team from Baylor Scott & White Health and Texas A&M Health Science Center College of Medicine. The research was presented recently at the CHEST Annual Meeting 2015 in Montreal.
The analysis indicates that sicker patients were triaged quickly to the ICU and had a shorter ED length of stay. When the researchers looked at additional variables that could impact mortality in severe sepsis – ED triage to antibiotic time, triage to lactate time, lactate clearance, ED length of stay, and variations in volume of IV fluids – no significant differences were found between the ED vs. the ICU, except initial lactate value and shorter lengths-of-stay (LOS) in the ED. Study authors note that both of those variables indicate sicker patients and were linked to higher mortality rates.
"Our study found that the sickest patients were more quickly triaged to the ICU. Those patients who were less sick and kept in the ED for longer time had lower mortality," lead researcher Aruna Jahoor, MD, of Baylor Scott & White Health Central Division, said. “These results suggest that identification and immediate treatment may positively impact survival in sepsis – no matter the hospital location of that patient."
For the study, the researchers looked at consecutive adult patients admitted with severe sepsis from the ED to the ICU from 2010-13. Results indicate that the 164 patients with severe sepsis had an in-hospital mortality rate of 26.8%, a 28-day mortality rate of 32.3%, and a use of invasive mechanical ventilation rate of 45.1%.
Compared to those who were in the ED less than six hours, sepsis patients in the ED for six hours or longer had significantly better outcomes for in-hospital mortality –relative risk of 1.86 –and 28-day mortality –relative risk of 1.79.
“We determined that a shorter ED LOS identified sicker patients at higher risk of mortality,” the authors write. “Spending a longer time in the ED was not associated with adverse outcomes.”
Therefore, the researchers suggest, “septic patients may be stabilized in an ED setting without risk of increased mortality from delayed ICU admission.” They caution, however, that their study was limited by a small sample size in a single institution.
Related [On-Demand Webinar]: Sepsis in the Era of 405 Regulations
Why Dietary Supplements Send Patients to the ED
ATLANTA – It might come as a surprise to dietary supplement advocates who believe they always are perfectly safe, but the lightly regulated products send more than 20,000 users to the emergency department each year.
A special article published recently in The New England Journal of Medicine suggests that, from 2004 through 2013, dietary supplements were implicated in an average of 23,000 ED visits and 2,000 hospitalizations annually.
“Although the numbers of emergency department (ED) visits and hospitalizations were less than 5% of the numbers that have been reported for pharmaceutical products previously, dietary supplements are regulated and marketed under the presumption of safety,” write researchers from the CDC.
ED physicians likely have noticed how many of the patients presenting with supplement-related adverse reactions are between 20 and 34. In fact, 28% of ED visits related to supplement use are by young adults, who are considered least likely to have problems with the products, according to the study.
The worst offenders? Weight-loss or energy compounds. Users often come to the ED because of cardiac symptoms such as palpitations, chest pain, or tachycardia.
“Notably, cardiac symptoms were documented more frequently in emergency department visits for adverse events associated with weight loss (43%) and energy products (46%) than for prescription stimulants,” study authors point out, adding that a previous study found that only 23% of ED visits were related to prescription stimulants.
The elderly and children, who are considered most vulnerable to side effects, also regularly present with the ED with supplement-related problems.
For children, unsupervised ingestion is responsible for more than 21% of all estimated ED visits for supplement-related adverse events. Products most commonly involved are multivitamins (33.6%), iron supplements (11.8%), supplements for weight loss (10.4%) and supplements for sleep, sedation, or anxiolysis (8.8%).
Older adults aren’t exempt from adverse reactions either. For them, swallowing problems caused nearly 40% of ED visits related to supplements. Micronutrients were implicated in more than 80% of those visits.
The study notes that, while the FDA recommends limiting the size of pharmaceutical tablets to 22 mm and requires the reporting of tablet size and shape on abbreviated new-drug applications, no similar size recommendations or similar reporting requirements exist for dietary supplements.
“Large amounts or multiple types of micronutrients are often packaged in a single large pill, and many micronutrient products approaching or exceeding 22 mm are commercially available,” the study authors write, adding, “Considerations for reducing the number of emergency department visits for swallowing problems include decreasing the size of supplement pills or using other delivery vehicles (e.g., liquids, gels, or powders), particularly for micronutrients for older adults, along with educating patients on methods for avoiding swallowing problems."
CT Scans, Criticized for Downsides, Also Are Beneficial for ED Diagnosis
BOSTON – With all of the concerns about the costs and risks of using CT scans in the emergency department, some of the benefits might be overlooked, according to a new study finding those benefits to be substantial.
The report, published online recently by the journal Radiology, finds that, after viewing CT scan results, physicians in the EDs of four major academic medical centers made key changes in clinical decision-making for patients with common presentations.
Researchers from the Massachusetts General Hospital (MGH) Institute for Technology Assessment suggest their results add critical information to health policy debates about the appropriate use of CT scanning.
"Emergency department physicians who face increasing pressure to make clinical decisions quickly are sometimes criticized for ordering too many CT scans that may not be clinically justified," explained lead author Pari Pandharipande, MD, MPH, director of the MGH Institute of Technology Assessment. "We found that – for patients with abdominal pain, chest pain or shortness of breath, or with headache - physicians' leading diagnoses and management decisions frequently changed after CT and that diagnostic uncertainty felt by physicians was alleviated."
Use of CT scanning has more than tripled in EDs over the past 20 years, but the benefits of increasing those procedures have not been clear, leading to complaints about over-reliance on imaging despite costs and increased radiation exposure for patients.
For the study, conducted between July 2012 and January 2014, ED physicians, both staff and residents, were asked to complete brief surveys after their initial evaluation of patients with abdominal pain, chest pain/shortness of breath, or headache. They then were asked to complete a new survey after receiving CT scan results.
While pre-CT surveys queried respondents about an initial diagnosis, the clinician’s confidence in that diagnosis, any alternative diagnoses that should be ruled out and current management decisions, post-CT surveys asked whether the initial diagnosis had changed, whether the CT scan had helped to confirm or rule out alternative diagnoses, and whether management decisions had changed.
With 245 physicians completing both surveys for 1,280 patients, diagnoses changed for 51% of patients with abdominal pain, 42% of patients with chest pain/shortness of breath and 24% of patients with headache.
In addition, the scans changed decisions about whether patients required hospital admission in 116 of 457 patients with abdominal pain (25%), 72 of 387 with chest pain and/or dyspnea (19%), and 81 of 426 with headache (19%).
"While there was a wide spectrum of diagnostic confidence before CT, the greater a physician's initial confidence in a diagnosis, the less likely that diagnosis was to change after CT, indicating that physicians were sound judges of their own diagnostic certainty,” Pandharipande, also an assistant professor of radiology at Harvard Medical School, said in an MGH press release. “But even in instances where physicians' pre-CT confidence in their initial diagnosis was greater than 90%, there were still changes in from 4% to 21% of cases.”
Related [On-Demand Webinar]: New CMS Radiology & Nuclear Medicine Hospital CoPs
Troponin Test Could Rule Out Heart Attack in Chest Pain Patients
EDINBURGH, UK – A new high sensitivity blood test could rule out a diagnosis for acute coronary syndrome in two-thirds of patients presenting to emergency departments, according to a new study.
The research on a test to identify the optimal level of troponin appeared recently in The Lancet. University of Edinburgh researchers and colleagues suggest that using the test in routine practice could double the number of patients found suitable for immediate discharge from the ED.
"Until now there were no quick ways to rule out a heart attack within the emergency department," lead author Anoop Shah, MD, said in a press release from The Lancet. "We have identified a cardiac troponin concentration (less than 5 nanograms per deciliter; <5 ng/L) below which patients are at very low risk of heart attack either during the admission or in the ensuing 30 days. These patients are therefore potentially suitable for immediate and safe discharge from the emergency department. These findings could dramatically reduce unnecessary hospital admissions and provide substantial cost savings for healthcare providers."
Background information in the article notes that international guidelines recommend that patients presenting with chest pain be admitted to hospital for testing for very high levels of troponin – above the 99th percentile – which indicates that a heart attack has occurred. In general, patients must either be hospitalized or have a lengthy stay in the ED for the testing.
While high-sensitivity cardiac troponin tests currently exist, study authors says it was unclear until now whether they could identify very low-risk patients who could be safely discharged from the ED.
The study used a test more sensitive than the standard version and which can detect far lower levels of troponin in the blood. Troponin levels were measured in more than 6,000 patients with chest pain admitted to four hospitals in Scotland and the United States, with researchers prospectively evaluating the negative predictive value of a range of troponin concentrations for heart attack or subsequent death from a heart condition after 30 days.
According to the results, a troponin threshold of less than 5 ng/L at presentation identified 61% of patients at very low risk of acute coronary syndrome – and who likely could be safely discharged – with a high negative predictive value of 99.6%. The high negative predictive value persisted despite, sex, cardiovascular risk factors, or prior cardiovascular disease. After a year, those patients had a three times lower risk of heart attack and cardiac death than those who had troponin levels 5 ng/L or higher, the study notes.
“Low plasma troponin concentrations identify two-thirds of patients at very low risk of cardiac events who could be discharged from hospital. Implementation of this approach could substantially reduce hospital admissions and have major benefits for both patients and health-care providers,” study authors conclude.
Writing in a linked comment, Louise Cullen and William Parsonage from the Royal Brisbane and Women's Hospital, Queensland, Australia, and Martin Than from Christchurch Hospital, New Zealand, call for clinical trials to develop guidelines that involve no further testing for patients with low troponin concentrations.
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