ED Push - August 2016 First Issue

EDs Often Fail to Diagnose Delirium in Advanced Cancer Patients

HOUSTON – Delirium in patients with advanced cancer is fairly common in the emergency department but remains undiagnosed in many cases.

That’s according to an article published online in the journal Cancer.

The research led by The University of Texas MD Anderson Cancer Center suggests that the condition is similarly common among older and younger patients and advises that all patients with advanced cancer be considered at higher risk for delirium.

Background information in the article notes that studies of delirium, the most common neuro-psychiatric syndrome in patients with advanced cancer, tend to focus on the palliative cancer care setting or solely on elderly patients in the ED.

For this study, researchers compiled a random sample of 243 English-speaking advanced cancer patients, ranging in age from 19 to 89 years old, who presented to the ED. The Confusion Assessment Method (CAM) was used to screen for delirium, and the Memorial Delirium Assessment Scale (MDAS) was employed to measure delirium severity with a scale of mild (less than 15), moderate (16-22), and severe (greater than 23).

Results indicate that 9% had CAM-positive delirium and a median MDAS score of 14. Among CAM-positive patients, delirium was mild in 82% and moderate in 18%, according to the MDAS finding.

Interestingly, patients aged 65 years and older were less likely to have CAM-positive delirium, 10%, than those younger than 65 years, 12%. At the same time, emergency physicians failed to detect delirium in 41% of CAM-positive delirious patients, according to the report.

"We found evidence of delirium in one of every ten patients with advanced cancer who are treated in the emergency department. Given that we could only study patients who were able to give consent to enter our study, even ten percent is likely to be a low estimate," explained study leader Knox Todd, MD, MPH, in an MD Anderson press release. "We also identified many psychoactive medications that could have contributed to delirium, and sharing this information with treating oncologists may help them avoid such complications in the next patient they treat."

“Delirium is relatively frequent and is underdiagnosed by physicians in patients with advanced cancer who are visiting the ED. Further research is needed to identify the optimal screening tool for delirium in the ED,” write study authors who also point out that their research is an example of the importance of the ED as a setting for monitoring the quality of cancer-related care and its potential role in preventing complications of cancer treatment.

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When Does Transport to a Distant Primary Stroke Center Make Sense?

LEBANON, NH – It’s a frequent dilemma when stroke occurs: Should the patient be transported to a primary stroke center (PSC), which offers specialized care, or will the extra travel time mitigate the benefits?

An article published online by JAMA Internal Medicine provides a fairly straightforward answer: Hospitalization of patients with stroke in PSCs was associated with decreased seven-day and 30-day case fatality compared with noncertified hospitals.

Yet, the Dartmouth-Hitchcock Medical Center-led study suggests that traveling at least 90 minutes to receive care offsets the 30-day survival benefit of PSC admission. To reach that conclusion, researchers analyzed data for a national group of Medicare beneficiaries and calculated travel time.

With stroke a leading cause of death and long-term disability in the United States, PSCs certified by The Joint Commission have been established to ensure adherence to guidelines and the efficient delivery of disease-specific care. Yet, incentives to direct patients with stroke to regional PSCs can affect travel times and outcomes, according to the report.

Using a study period from 2010 through 2013, researchers focused on 865,184 Medicare fee-for-service beneficiaries, average age nearly 79 years, who presented with a stroke. Slightly more than half of the patients, 53.9%, were treated at one of 976 PSCs across the country, with about 24% of them living closer to a PSC than to a non-PSC facility.

Results indicate that admission to a PSC was associated with a 1.8% lower seven-day and 30-day death rate, but that traveling at least 90 minutes to a PSC appears to offset any mortality benefits. Presented another way, the study suggests 56 patients with stroke need to be treated in PSCs to save one life at 30 days. For seven-day outcomes, the study posits that 60 minutes of travel time for a PSC admission could be the offsetting factor.

"Further investigations are necessary to identify the best combination of approaches to improve access to centers of excellence and stroke outcomes," the authors conclude.

In a related commentary, Lee H. Schwamm, MD, of Massachusetts General Hospital and Harvard Medical School, both in Boston, writes that, “Within the limits of their Medicare (Centers for Medicare & Medicaid Services) fee-for-service claims data source, [researchers] did an elegant job of trying to control for measured and unmeasured confounding introduced by the nonrandom allocation of patients.”

“The most cost-effective sorting and allocation strategies will occur in the context of a unified stroke system of care that brings together centers of varying capability that are publicly reporting their performance data, engaged in continuous quality improvement, and focused on what is best for patients,” Schwamm adds. “Smartphone apps or similar methods are needed that can factor in the onset time, degree of stroke severity, travel times, hospital door-to-needle and door-to-puncture times, rates of recanalization success, patient preference, and in-hospital mortality to determine the best possible destination for each patient.”

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Too Many Trauma Centers Can Lower Volumes, Increase Death Rates

PITTSBURGH – New research finding that higher patient volume improves outcomes emphasizes the importance of taking that into consideration when designating a new trauma center in a region.

A study published in Annals of Surgery finds, for the first time, that changes over time in the volume of patients seen by trauma centers can influence the survival of seriously injured patients.

"It takes about three years for the impact of increased patient volume to translate into improved patient outcomes," said lead author Joshua Brown, MD, MS, a research fellow in the Division of Trauma and General Surgery in the University of Pittsburgh School of Medicine's Department of Surgery. "Siphoning of patients through unregulated growth of unnecessary trauma centers can have a profound detrimental impact on patients that isn't immediately obvious. Before designating a new trauma center, serious consideration should be given to how that designation will affect patient volumes over time at trauma centers throughout the region."

For the study, researchers examined records of nearly 840,000 seriously injured patients seen at 287 trauma centers between 2000 and 2012. The centers averaged 247 severely injured patients per year, and 90% of the cases involved blunt injury.

The researchers compared the center’s actual death rate to the expected death rate if everything involving each trauma patient's care had gone perfectly.

Results indicate that each 1.0% increase in patient volume at a trauma center was associated with 73% better odds of a patient surviving. At the same time, each 1.0% decrease in volume was linked to a two-fold worsening in the odds of a patient surviving.

"So, the study suggests the negative impact of declining patient volume is significantly greater than that of the positive impact of increasing patient volume," explained senior author Jason Sperry, MD, MPH. "Granting unnecessary designation to a trauma center in a region that doesn't have the patient volume to support it not only hurts patient outcomes at that new center, but it will likely lead to a decline in patient outcomes at other nearby centers."

While study authors concede that they don’t fully understand how patient volume is linked to outcomes, they theorize that, as trauma centers increase their number of patients, they also increase their resources, infrastructure, and experience.

That might not be the full explanation, however.

"Taking care of patients who sustain complex traumatic injuries is a truly multidisciplinary effort, so it requires an institutional-level commitment of resources and staff," Brown pointed out in a University of Pittsburgh Schools of the Health Sciences press release. "There are many dynamics at play here that make the issue more involved than simply increased opportunity to hone surgical skills."

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Early Initiation of Blood Thinners Effective, Safe in TBI Patients

TORONTO, CANADA — Initiating blood thinners within 72 hours of hospital arrival significantly lowers the likelihood of life-threatening blood clots in patients with traumatic brain injury (TBI) but doesn't increase the risk of bleeding complications or death, according to a new study.

The article published online by the Journal of the American College of Surgeons notes that pulmonary embolism (PE) is a leading cause of death in patients who sustain a TBI, and that they also are at high risk of developing deep vein thrombosis (DVT).

The University of Toronto-led study suggests that starting blood thinners early can have a significant protective effect against those conditions.

"Physicians have traditionally been hesitant to initiate pharmacological blood clot prophylaxis early in patients with severe brain injuries because, while thinning the blood might prevent PE and DVT, it might also increase the risk of complications related to worsening intracranial hemorrhage," according to lead study author James P. Byrne, MD, a general surgery resident and PhD student at the University of Toronto. "We performed this study because there wasn't clear evidence that starting prophylaxis early actually prevented blood clots, or whether this benefit would outweigh the risk of complications from intracranial hemorrhage. Current evidence-based guidelines don't address the optimal timing for starting prophylaxis in patients with severe TBI."

Background information in the report notes that TBI patients are at higher risk of forming blood clots because of hypercoagulability related to their injuries and long-term immobility.

For the study, researchers analyzed data on 3,634 adult patients with severe TBI who were treated at 186 trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP). Included was TQIP data for all patients who had received prophylaxis with either low-molecular weight heparin or unfractionated heparin between 2012 and 2014.

The study sought to compare the effectiveness of early vs. late prophylaxis, and to evaluate the potential risks of worsening intracranial hemorrhage. Patients were divided into two groups: early prophylaxis (started within 72 hours of arrival at the hospital) or late prophylaxis (started after 72 hours), with PE or DVT defined as primary outcomes.

In an effort to characterize complications related to intracranial hemorrhage, the study team also included two secondary outcomes: late neurosurgical interventions (performed after 72 hours) or in-hospital death.

Results indicate that odds of both PE and DVT were 50% lower in the early prophylaxis group than in the late prophylaxis group. On the other hand, no difference was detected with late neurosurgical interventions or in-hospital death between early prophylaxis and late prophylaxis groups.

The study also reports that trauma centers that most frequently used early prophylaxis in their patients had significantly lower rates of DVT, compared with those where fewer patients received early prophylaxis, but no difference in rates of late neurosurgical intervention or mortality.

"The takeaway message is that early prophylaxis really does matter in patients with severe traumatic brain injury, in terms of reducing a patient's risk of pulmonary embolism or deep vein thrombosis," Byrne emphasized. "Our findings suggest that this is possible without increasing the risk of the most feared complications, such as the need to take a patient to the operating room to evacuate intracranial hemorrhage, or death. In other words, it's possible to prevent PE or DVT with early prophylaxis, without putting patients at risk of bad outcomes, and we should be striving to achieve this.”

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