ED Push - January 2016 First Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Debate Continues: Antibiotics Only or Surgery for Uncomplicated Appendicitis?
COLUMBUS, OH – When a child presents to the emergency department with uncomplicated acute appendicitis, is using antibiotics alone for treatment a reasonable alternative to surgery if that is the family’s choice?
It’s all according to who you ask.
A study led by researchers at Nationwide Children's Hospital in Columbus, OH, found that three out of four children with uncomplicated appendicitis had been successfully treated with antibiotics alone at one year follow-up. The report, published recently in JAMA Surgery, notes that, in comparison with urgent appendectomy, non-operative management was associated with less recovery time, lower health costs, and no difference in the rate of complications at one year.
"Families who choose to treat their child's appendicitis with antibiotics, even those who ended up with an appendectomy because the antibiotics didn't work, have expressed that, for them, it was worth it to try antibiotics to avoid surgery," said lead author Peter C. Minneci, MD, in a Nationwide Children’s press release. "These patients avoided the risks of surgery and anesthesia, and they quickly went back to their activities."
A surgeon-led analysis -- which looked only at adults -- argues, however, that it is too early to change the standard treatment of appendicitis in the United States to initial antibiotic therapy only, rather than surgical removal of the appendix.
The ”article in press” on the Journal of the American College of Surgeons website notes that prompt appendectomy has been the standard treatment of appendicitis for more than 120 years. It also refers to articles over the last two decades concluding that some patients with acute uncomplicated appendicitis can be treated with antibiotics alone.
"Despite the generally low rate of complications after appendectomy, some U.S. physicians and the public are questioning whether we should change to non-operative treatment of appendicitis, as many surgeons in Europe already have done," said that study's lead investigator, Anne P. Ehlers, MD, of the University of Washington, Seattle.
"What we found in our review is that antibiotics-first treatment of appendicitis is probably safe for adults and successful in 3 out of 4 patients,” Ehlers added in an American College of Surgeons press release. “However, there are many unanswered questions about outcomes of antibiotics-first treatment that patients have told us are important to them.”
The Nationwide Children’s study enrolled 102 patients ages 7 to 17 who were diagnosed with uncomplicated acute appendicitis between October 2012 and October 2013. Participants had early/mild appendicitis, with abdominal pain for no more than 48 hours, a white blood cell count below 18,000, had undergone an ultrasound or CT scan to rule out rupture and to verify that their appendix was 1.1 centimeter thick or smaller and had no evidence of an abscess or fecalith.
The 37 patients whose families had opted for antibiotics were admitted to the hospital and received IV antibiotics for at least 24 hours, followed by oral antibiotics after discharge for a total of 10 days; 95% showed improvement within 24 hours and were discharged without undergoing surgery, according to the results.
Surgery was chosen for another 65 patients, with rates of appendicitis-related medical care within 30 days found to be similar between the groups.
Two patients in the non-operative group were readmitted within 30 days for an appendectomy, but, at one year after discharge, three out of four patients in the non-operative group did not have appendicitis again and had not undergone surgery, study authors report.
Medical ‘Super Glue’ Keeps ED Peripheral Intravenous Devices in Place
BRISBANE, AUSTRALIA – In a busy emergency department, reinserting peripheral intravenous devices (PIVs) is a time thief, especially since more than 1 in 10 of them simply fall out.
The solution, according to an Australian study recently published in Annals of Emergency Medicine? Medical-grade “super glue.”
Tissue adhesive, i.e. cyanoacrylate, is used for everything from closing skin lacerations and wounds as an alternative to sutures or staples to repairing gastric varices, inguinal hernias, bones, tendons, and retinal detachments.
A study team led by researchers from Caboolture Hospital and the University of Queensland conducted a single-site, two-arm, non-blinded, randomized, controlled trial of 380 peripheral intravenous catheters inserted into 360 adult patients.
While the control group received standard securement, a second group received standard securement in addition to cyanoacrylate skin glue applied to the skin insertion site.
The success of the intervention was determined by peripheral intravenous catheter failure at 48 hours, regardless of cause. The researchers also looked at individual modes of peripheral intravenous catheter failure, infection, phlebitis, occlusion or dislodgement.
Results indicate that peripheral intravenous catheter failure was 10% lower with skin glue (17%) than standard care (27%), and dislodgement was 7% lower. While rates of phlebitis and occlusion were lower with skin glue, the difference was not statistically significant. No infections were identified.
“This study supports the use of skin glue in addition to standard care to reduce peripheral intravenous catheter failure rates for adult emergency department patients admitted to the hospital,” study authors conclude.
An earlier study in Brisbane, which looked at PIV failure across the hospital setting, discussed the benefits of avoiding it, noting that “despite a high clinical need and the high costs to hospitals for products given the significant volume of use, there is a paucity of studies reporting the efficacy of alternative dressing and securement methods. Rigorous assessment of the efficacy and cost-effectiveness of PIV dressing and securement methods is therefore needed to guide clinical decision-making. If failure rates can be reduced by 10%, this would prevent more than 30 million PIV failures and reinsertions in the USA each year alone, with phenomenal associated reductions in health costs and nursing/medical time."
Prescribing Guideline Significantly Reduces ED Prescriptions for Opioids
PHILADEPHIA – Are opioid prescribing guidelines a valuable tool or just another bureaucratic interruption to slow down care in the emergency department?
The former, it would seem. According to a recent article in the Journal of Emergency Medicine, an opioid prescribing guideline at Temple University Hospital in Philadelphia had an immediate positive effect on reducing opioid prescribing rates for minor conditions and chronic non-cancer pain in an acute care setting.
With emergency departments a common target for opioid drug-seekers, physicians struggle to maintain a balance between providing appropriate analgesia for patients without creating or exacerbating drug dependence, according to the study authors.
After the U.S. Department of Health and Human Services recommended that pain management guidelines and the clinical decision support tools be created, Temple University Hospital (TUH) and Temple University Hospital-Episcopal Campus (TUH-Episcopal) complied.
"The impact of this type of guideline had never been studied in an acute care setting," said principal investigator Daniel del Portal, MD, FAAEM. "We hypothesized that the rate at which opioids were prescribed in the emergency department for dental, neck/back, and chronic pain would decrease after adoption of the guideline. We also hypothesized that physicians would support the use of the guideline."
For the retrospective observational study, which compared the rate of opioid prescriptions for dental, neck/back, and chronic non-cancer pain before and after adoption of the guideline in January 2013, researchers used data from 13,187 patients aged 18 years or older who met the diagnosis criteria and were discharged from the ED at the two Temple hospitals. In addition, a survey was administered to emergency medicine physicians who were practicing in the two EDs.
According to the study, the rate of opioid prescribing decreased from 52.7% before the guideline to 29.8% immediately after its introduction, and to 33.8% 12 to 18 months later. The decrease in opioid prescriptions was across the board, the authors report, observed in all diagnosis groups and age groups reviewed.
With nearly 100% of the physicians surveyed saying they supported the voluntary guideline, most reported that the guideline had facilitated discussions with patients when opioids were being withheld. In addition, nearly three-quarters of respondents reported encountering less hostility from patients since adoption of the guideline.
"Emergency physicians and other acute care providers can use various tools to promote the rational prescribing of dangerous opioid medications," del Portal added in a Temple press release. "In contrast to electronic prescription drug monitoring programs, which show promise but require significant infrastructure and regulation (and are as yet unavailable to prescribers in Pennsylvania), an easily implemented guideline empowers physicians and protects patients from the well-documented dangers of opioid misuse."
ED Treatment Delays for Previous CABG Patients with STEMI
STONY BROOK, NY – There might be a good reason for it, but ST-segment elevation myocardial infarction (STEMI) patients who had previously undergone coronary artery bypass graft surgery were much less likely than other heart attack patients to be treated within the 90-minute recommended “door-to-balloon time.”
That was even the case when those patients were compared to a similar cohort with prior angioplasty, according to a study published in JACC: Cardiovascular Interventions.
The investigation led by Stony Brook University Hospital researchers was dubbed a “call to action” to increase response time for heart attack patients who had previously undergone CABG surgery.
The study used data from the National Cardiovascular Data Registry CathPCI Registry linked with the ACTION Registry-GWTG. With examination of records of 15,628 heart attack patients treated at 297 U.S. hospitals between June 2009 and September 2011, 6% were found to have had a history of previous coronary artery bypass graft surgery, 19% with previous angioplasty, and 75% with no prior history of procedures.
The STEMI patients who previously had revascularization through surgery were older, an average age of 66, than those with prior angioplasty, average age 60, or without any previous interventions, average age 59. They also were more likely to have other co-morbidities such as high blood pressure, high cholesterol, and diabetes.
Just 76% of patients with prior CABG surgery were treated within the recommended 90-minute door-to-balloon time, compared to 88.5% of patients with prior angioplasty and 88% of patients with no previous interventions.
More specifically, door-to-balloon time was achieved in 90% of patients with a history of angioplasty with a stent when the new lesion was located in the previous stent and in 87.3% of patients if the lesion was in a non-stented area. For patients with a history of CABG, 75.9 of those with the new lesion in the graft site and 77% of those with a lesion in a new vessel had their angioplasty done within 90 minutes.
Overall, patients who had been treated with CABG had a lower rate of successful procedures, 88.3%, as opposed 93.4% of patients who had a prior angioplasty and 94.4% of patients with no prior interventions. No significant differences in in-hospital mortality, major adverse events, and major bleeding were identified among the three groups, however.
Lead author Luis Gruberg, MD, FACC, of Stony Brook University, conceded that patients with a history of coronary artery bypass surgery have more complex anatomy and more comorbidities, adding in an American College of Cardiology press release, "Nonetheless, every effort should be made to improve timeliness in patients with a history of previous coronary artery bypass surgery.”
"Increased awareness of 'time is muscle,'" John S. Douglas Jr., MD, of Emory University School of Medicine in Atlanta, wrote in an accompanying editorial, "may lead to shortened door-to-cath lab times and timely performance for the more difficult patients.”
Douglas said the study "should be interpreted as a 'call to action' with the goal of earliest possible treatment in all heart attack patients, including those who have had prior coronary artery bypass graft surgery."
UPCOMING [LIVE] WEBINARS
The Final CMS Worksheet on Infection Control
Live: January 13 Credits: 2 CE
TJC Sentinel Event Policy, Patient Safety Systems & CMS RCA Requirements
Live: January 20 Credits: 2 CE
Telemedicine, the Cost-effective Alternative: Real-time CMS & TJC Standards
Live: January 27 Credits: 2 CE
Altered Mental Status and Neurological Disasters
Live: January 28 Credits: 1.5 CE & 1.5 CME
New Pharmacy & Medication Standards: the CMS CoPs
Live: January 28 Credits: 2 CE
Advance Care Planning Payments and Standards
Live: February 3 Credits: 2 CE
Safe Opioid Use: Meeting the CMS CoP Hospital Requirements
Live: February 9 Credits: 2 CE
Violence Prevention in Healthcare: OSHA Requirements
Live: February 9 Credits: 1 CE
Restraint and Seclusion: The Most Problematic of All CMS Standards
Live: February 17 Credits: 1.5 CE
