Improving Outcomes, Improving Throughput, Radiology

Parting the SEA with the almighty H&P (& rapid MRI).

Necessity is the mother of invention, and sometimes, necessity comes in the form of hospital administration after a bad outcome. The authors of this paper, essentially developed a rapid MRI protocol for suspected spinal epidural abscess after “several cases of SEA associated with delayed diagnoses and poor outcomes prompted the chairs of the departments of emergency medicine, neurosciences, medicine, and radiology, and members of the Division of Healthcare Quality, to develop a multidisciplinary, clinical decision support tool and imaging protocol with the goal of facilitating early recognition of SEA.”

Wow. Talk about moving mountains. If you’re department is anything like mine, it takes hours to agree on where we’re getting take out from; I cant imagine adding in 4 entire departments into the lunch-ordering mix, let alone all agree on a protocol.

They took a relatively simple approach – if you have new or worsening back/neck pain AND a history of spinal abscess or current/recent (6 months) bacteremia, straight to MRI. I think the recent bacteremia often gets lost in the work up, so I appreciate that they put this front and center. If there is no recent spinal infection or recent/current bacteremia, They looked at risk factors- and I’ll make this simple and break it into 2 categories: people putting things where they dont belong (IVDA, vascular catheters, spinal procedures/injections) and the recurrently ill: ED visit or antimicrobial treatment within 30 days or an infectious process elsewhere. If yes, head to MRI.

I’m torn a bit on this- while I want to applaud the authors for not dwelling on a variety of risk factors that only a small portion of the population has – alcoholism, HIV, severe COPD, the undomiciled, HepC, oncology patients, transplant patients, etc; to say that this group is pretty much captured in the recent ED visit category probably misses a fair amount of patients on the first go-round. And here is the problem of trying to find a needle in the haystack – its hard to increase sensitivity and specificity without causing a delay at some other portion of the food chain – every stat MRI for so many additional back pain patients pushes out another patient and potentially extends at least 1 other patients length of stay.

However.

Despite an increase from 56 MRI’s in the 7 months pre-intervention to 147 in the 7 months post-intervention, yield for a positive MRI (defined solely as SEA and not vertebral osteomyelitis or infectious discitis), went from 16.1% to 17.7%.

On first glance, that’s not a lot of improvement in yield, but they screened 3 times as many patients without losing yield! This is rather impressive. However, they tripled their ED MRI rate, and, even though they drastically cut turn around times from 8.6 hours to 4.4 hours from time of MRI order to radiology report, thats still well over 4 hours for patients with back pain in a highly optimized system. And while yes, they missed fewer SEAs, they probably still have a good percentage that they missed on first visit – the various forms of immunocompromised – the severe COPDer on repeated steroid prescriptions, the HepC patient, the elderly – these are likely missed on the first go round.

I think this is a great step towards creating a policy towards SEA workup. It needs some refinement, but is the best I’ve seen yet. It poses some issues for smaller facilities that do not have 24/7 MRI capabilities, as well as for consultants (neurology essentially becoming a house officer for ID and neurosurgery), and poses a big time crunch for the ED (again, neurology took control of these cases once the decision to MRI was performed, which the hospitalists must be thankful for!). In the end, there is no such thing as zero miss, but Baystate, with this study, demonstrates that, at least for one day, the H&P is not dead.

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Improving Outcomes, Improving Throughput, Neurology

Opiates beget Opiates – Headache edition.

This is a study comparing 3 EDs in my homeland of CT and their (mis)use of opiates for headaches over a 14 month period. This compared an academic tertiary care center with an approximate 110,000 annual patient volume; an urban hospital with an approximate 85,000 patient annual volume, and a community ED that sees approximately 19,000 patients annually. A total of 1,222 visits were included for final analysis.

Results? Opiates, are not good, mmmmkay?

Patients given opioids as first line treatment had a 37.7% increase in visits over the study period compared to those who were not given opioids. If you were given opioids as first line, 36.0% required rescue treatment compared to 25.1% in those who were not given opioids. Strangely, female patients were significantly more likely to have opioids ordered than male patients (38.2% vs 24.2%).

Need more reason not to give opiates? Patients not given opioids had a 30.3% reduction in length of stay.

I’m surprised these numbers are so high.  As a community EM AP, I’m embarrassed at these numbers – A shocking 58% of headaches in a community setting were given opiates as first line compared to 6.9% of those at the academic center). Then again, opiates beget opiates.  Opiates lead to repeat visits, more rescue meds, and an increased length of stay, without an improvement in patient satisfaction with opiates.  I question how often those in the community ED just gave opiates to avoid conflict.

Just.  Stop.  Giving.  Opiates.  For.  Headaches.  NOW.

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Improving Outcomes, Mythbusting, Radiology, Radiology

Spinal Abscess: The Baystate Review

This is a review of all spinal abscesses at Baystate (total 162), from 2005 – 2015.  They compare 88 randomly selected controls whom had similar ICD-codes less the spinal abscess plus an MRI that was negative for acute infectious process. 

Interesting take home points, much of which is consistent with prior (albeit scant) literature:

-73% of patients are over age 50.

-more likely to have their second visit (50.6% vs 29.6% of controls) – though this 50.6% of patients with a second visit is surprisingly low for me – no word on how many were sent home from the ED, and had an MRI as an outpatient that were not included in this calculation.; or maybe we’re getting better at finding the needle in the haystack?  Or maybe we’re MRI’ing everyone?

-Many received antibiotics within the month: (35.2% vs 6.8% of controls) – this signifies a huge red flag for me.  If a patient revisits the ED and recently had pyelo (or anything infectious really), and now presents with back pain, probe a bit more for the possibility of vertebral osteo or discitis. 

-percentage of patients with history of IVDA: 20.4% vs 4.6% … this number seems low, but also is somewhat in line with prior studies – thus making me wonder how many I’ve missed…

– percentage of patients with alcoholism with a spinal abscess: 19% vs 8% – the more I get interested in ID, the more I realize that alcoholism is basically a form of immunosuppression.

-percentage of spinal abscess patients with obesity 21.6% vs 2.3%; I’m surprised only 2.3% of controls were obese.  Not sure what role this plays as being a diabetic in and of itself was not associated with a higher increased risk in this study.

-fever was present 62.4% in those with a spinal abscess vs 13.6% of those without; this includes self reported fever, which I have to wonder how often we sweep this aside when the patient is afebrile in the ED.

-16% had no identifiable risk factors; a third of the patients  presented with back pain, fever, neurologic deficits vs 6%

-Other symptoms and signs related to potential spinal cord impingement were seen with similar frequencies and of similar durations among cases and controls- meaning, focal deficits seen in both groups.

-noncontiguous co-infection: 53.7% of time (pneumonia, distant osteo, endocarditis… of those with a co-infection, 20% had more than one).

-blood cultures were positive 63.4% of the time, and >75% of the time it was staph Aureus. 

-Majority of lesions were found in the L-spine at 56.2%  – which means almost half are elsewhere!

-while “admits” for spinal abscess were up from 2.5 to 8 in 10,000 admissions from 2005 to 2015, I have to believe that number is somewhat inflated as admits like chest pain, pneumonia and renal colic probably decreased, while MRI became more readily available. 

All in all, this paper is pretty much in line with others on this topic, and strengthens the signal a bit for certain key points: a good number of spinal abscesses are not in the L-spine; many patients are older than you think, and, among other things: its more than just IVDA. 

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Cardiology, Cardiology, Critical Care, Improving Outcomes, Improving Throughput, Mythbusting, Pulmonary, Radiology, Radiology

Probing the dyspneic patient.

For undifferentiated dyspnea, how would you like to have an accurate diagnosis in 24 minutes?

I love this study.

Basically, for all dyspneic patients (not trauma related, and over age 18), 10 EP’s were given an H&P, vital signs, and an EKG, as well as access to a Chest X-Ray, Chest CT, cardiologist performed echo, and labs including an ABG.

These same 2,683 patients, in tandem, had point of care ultrasound testing (lung, IVC, echo). Here’s the catch – the ultrasonographers were only provided the H&P, vital signs, and EKG then asked to make a diagnosis. The treating provider was blinded to POCUS diagnosis.

These numbers for diagnostic accuracy of POCUS are astounding.

+LR for acute HF? 22 (-LR 0.12)

+LR for ACS? 105 !!!

+LR for pneumonia? 10.5 (-LR 0.13)

+LR for pleural effusion? 95 (-LR 0.23)

+LR for pericardial effusion? 325!!! (-LR 0.14)

+LR for COPD/asthma? 22 (-LR 0.14)

+LR for PE? 345!!!

+LR for pneumothorax? 4635!!! (-LR 0.12)

+LR for ARDS? 90

Yes, for certain things like pneumonia, the difference in p-values between tradition means and POCUS diagnosis was not significantly different, but what about volume status? I cant imagine blindly giving 30 cc/kg would benefit the patient with a plethoric IVC and pleural effusion. There is some elegance a play here.

Additionally, sure, ED diagnosis for ACS had a higher LR, but they also had a cardiologist performing and interpreting echos in the ED (a rather rare siting in a US ED I would imagine) – without much improvement in their -LR (0.53 vs 0.48). For PE, the -LR of POCUS was predictably mediocre if not outright bad (0.6), while the -LR for ED diagnosis of PE, with the benefit of chest CT, was -0.10.

Now look, I get that these EP’s were quite sono-savvy. They all had 2+ years of experience, over 80 hours of ultrasound lessons & training, with at least 150 lung and 150 ED echo’s under their belt. The diagnosis was made in 24 minutes with POCUS in comparison to 186 minutes for traditional means. And while most of us can not do a year+ ultrasound fellowship, and neither can we all be as savvy with the probe as these authors (or Matt, Mike, Jacob, Resa, Laleh, etc) – it does not mean we shouldnt try. You can still greatly increase your yield just by practicing. To boot, the cognitive offload you experience by saving yourself a few hours by (correctly!) knowing which direction you are heading with a patient is an immense boon to both your mental heath & your patients well being.

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Improving Throughput, Mythbusting

More No-Value Care: pre-procedure INR for cirrhotics

You have a cirrhotic patient in front of you. They need a procedure. You reflexively order a cbc, comprehensive metabolic panel, and PT/INR because you’d like to know about their platelets/ liver enzymes / coagulation ability.

Or maybe it’s a consultant who refuses to do a procedure the patient needs until you order these tests.

And then the platelets come back at 40; or maybe the INR returns at 1.4. Now what?

Do we need to transfuse platelets or FFP? Well, this case series looked at 852 consecutive cirrhotics from Jan ’11 – March ’14 who needed an invasive procedure the decision to transfuse PLT / FFP at attending discretion. Here’s a breakdown of their patient demographics:

screen-shot-2017-02-18-at-7-47-52-pm

And the number of complications:

screen-shot-2017-02-18-at-7-48-04-pm

Now, sadly, despite discussing the World Health Organization classification for bleeding events, they did not really get into the severity of bleeding events. With that said, complications were unrelated to platelet count, INR, CHILD classes, and MELD score. Only 1 in 379 paracentesis had a bleeding event, and only 2 of 228 TIPS/ CVC/ PICC/ hemodialysis/ I&D procedures had an event.

Perhaps most importantly, while attempts to normalized PLT and INR values, PLT/FFP transfusions barely affected the corresponding abnormalities, the scheduled invasive investigations were carried out in the presence of still subnormal parameters- with no or only a few bleeding complications.

Ergo, I agree with the authors, – “we have verified clinically the futility of this recommendation.”

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Improving Outcomes, Improving Throughput, Radiology

Ultrasound MiniFellowship, eh?

Are you looking for a bridge after taking an ultrasound course at a conference?  Do you feel like you need a bit more oversight until you get comfortable with probe in hand?  Are you having trouble conceptualizing what it means to have ultrasound guide your practice in the critically ill?… Read on.

I recently had the pleasure of attending a CCUS POCUS mini-fellowship –  it was everything I was hoping for & more- and has pushed me to be a better clinician.

First, a blurb about ultrasound fellowships.  As a PA, there isn’t really any hands on US training during our programs.  There likely is some POCUS for PA EM residents – but most practicing EM PA’s are not residency trained.  Therefore, we’re at the mercy of our co-workers who may (or may not) have any US training.  It’s hard to learn POCUS when you don’t have someone over your shoulder to guide you!

I had done a few ultrasound courses, but was struggling to really implement it into my practice regularly.  Ultimately, this was my own fault.  I was repeatedly told to pick up the probe and practice.  Literally, every sono-savvy person has told me this.  A large part of my problem was that I did not pick up the probe immediately after courses to drill down on fundamentals – and scan every person regardless of their complaint.  This is not meant to disrespect those that I took courses with before – they were *extremely* helpful and I’m incredibly thankful for their expertise! – the fact that I continued to seek out ultrasound training is a testament to prior courses showing me the importance of developing this tool set.  Now, onto Canada.

I ended up taking a 2 day course with Philippe Rola in Montreal.  Philippe is extremely responsive via email, we had spoken on the phone a few times prior to my arrival as well.  He’s friendly, approachable, and has been doing mini-fellowships since 2009 (!).

I was looking to optimizing views, particularly on patients with challenging anatomy (I mean, have you seen the average American BMI recently?), and what started with, “where the hell is the IVC” turned into, “This is a plethoric IVC.”  While it might be that the 3rd (or is it 4th?) time is the charm for courses for me, and that I would get it eventually via spaced repetition, but there is something about practicing on patients with acute illness and watching Rola make decisions based on POCUS in real time that helps put the pieces together a bit faster.

I believe the main advantage of this US course is the real time feedback on real patients… and if you are there for more than one day, you get to watch the ICU story unfold.  You see about 10-12 patients in their ICU, and a handful of ICU consults on the floors or in the ED.  You may or may not go to a rapid response, and see how it really makes a difference in the heat of the moment.  Fortunately, this is not reminiscent of your student days when the mentor says, “You’ll have to sit this out, this one’s mine, sorry.”  Philippe was extremely patient with me in the hypotensive altered patient while I scanned.  He’s excellent at questioning at just the right time to help tie it together- “ok, what are you seeing? A plump IVC and some pleural effusions in this hypotensive patient?  So whats your next step?”

To maximize your experience, I would strongly encourage you to have 1-2 specific goals in mind like, “I want be able to consistently visualize the IVC and have a few back up views just in case.” Expecting more than 1-2 things is probably spreading yourself thin.  You’re not going to become a pro overnight.  Be upfront & honest with Rola – he can tailor to your skill level- whether it be an assessment of valvular function or just wanting to visualize the heart.  Philippe had recommended 2-3 days at a time, which I agree with – I think after 2-3 days you reach the point of diminishing returns and “get full.”  You need some time to process what you’ve learned, and to practice on your own (before going back!).

Upon my return home, I made it a point to utilize the probe on my next shift.  If at all possible, I would recommend arranging shifts to be “main ED” shifts when you get back home such that you see the belly pain, shortness of breath, and chest pain patients so that you can apply what you learned immediately.  I did this on my first shift back with the hope of scanning 5 patients or more – I literally brought the machine with me when I walked into the room.  Surprisingly, I thought it would slow me down.  This was not the case at all.  I also realized a major benefit that I was not expecting.  The cognitive offloading of using the probe and eliminating some of the guess work kept me fresher longer. I saw more patients than average, with sicker than average patients, and it did not feel like taxing shift at all.  I didnt have to task switch to check on that xray or CT nearly as much as I usually do (though I was still ordering what I usually would to confirm suspicions since I’m still early in POCUS training)…. I would be interested to see the throughput of docs using POCUS vs those not, and I’d also like to see the level of “decision fatigue” at the end of a shift – I’m convinced that POCUS provides a significant cognitive offload to the EM provider, and the POCUS’ers are less fatigued at the end of their shift.

Bottom line, I think I needed other courses to whet my appetite and open the door, and I needed Montreal to push me through the door and get me to start practicing more.  If you work in an environment where you don’t have much POCUS backup and want to learn with one of the best and don’t want to break the bank, come to Montreal!

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Improving Throughput, Mythbusting, Pediatrics

Inching closer to discharging an ICH from the ED?

A few years ago, I was with an attending who was discharged a pediatric patient.  Staff in general seemed hesitant, but this was a well-loved doc who’s reply was somewhere along the lines of, “this kid looks great! Do you know how many times my kids probably had a bleed and did fine? We over CT these young things! And if he has a bleed, what are they really going to do anyway besides charge a lot of money for no appreciable intervention?”

And with that, comes this retrospective single center study of 202 children 0-18 years of age with an acute CHI, an abnormal CT (defined as both nondepressed and depressed skull fractures, subdurals, epidurals, subarachnoids, intraparenchymal hemorrhage, and intraventricular hemorrhage), and a GCS 14 or higher.

Essentially, the question is, can these patients be safely treated in an obs unit?

Exclusions were multisystem trauma, nonaccidental trauma, prior neurosurgical conditions and coagulopaths were excluded as well.   86% of patients were 5 years of age and under, and only half of all patients presented to the ED in under 6 hours.  My first reaction to this was “huh?” –  but the authors go on to state the 73% of patients had a hematoma, 11% had LOC, 30% vomited, 28% had a change in behavior, etc… so I guess it makes sense that there was a delayed presentation since parents may have initially thought their child was alright, only to later to suspect something was afoot (or perhaps patients were transferred to their ED from outside facilities?).

Fun sidenote: 17% of patients had no exam findings, so I gotta ask – why were they scanned?  To put it another way, much like the aforementioned doc had asked- how many kids have we discharged without a head CT with clinically insignificant ICH?

 

So what did the authors find?  ZERO children were intubated, required neurosurgical intervention, PICU admission, or died.  All were discharged within 72 hours, and 86% of patients with >1 CT finding were discharged within 24 hours!   Surprisingly, this is actually somewhat consistent with prior studies.

 

Ultimately, before starting this at your institute, note that there are some subtleties in the data- like that 25% epidurals with a repeat CT (3 of 12) showed a larger bleed. But really, looking at the data on patients that were admitted, I have to ask – which of these *really* needed an admission? None had an intervention aside from continued analgesia / anti-emetics.

 

Of note, this hospitals EDOU had an admission rate of 3-4 % – wayyyyy below national average of 15-20% – so either they’re sending home a ton of kids from obs unnecessarily, their ED is placing way too many in obs, or the rest of us have it wrong.  Which leads me to agree with the authors on the following:

“For those well-appearing children in whom CT abnormalities are visualized, an EDOU is still an appropriate place for these patients, or should early discharge with home observation also be considered?”

 

Will we see a time when certain types of head bleeds are treated like low risk chest pain – accelerated protocols and an abundance of EBM suggesting early discharge? Or arranging for telemedicine to circumvent many of these transfers to tertiary care centers?

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