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, 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 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, Radiology, Radiology

Whaddaya Mean You Can’t Learn POCUS?

After taking a few one day ultrasound courses, a common theme amongst classmates is something to the effect of, “well, I get it now, but what about next week when the instructor isn’t there to guide me?”

Admittedly, I have wondered about the same thing; and wondered about the retention of knowledge and ability to apply what you have learned at these 1-2 day crash courses.

So you think you cant learn ultrasound? Or that you can not retain it after a weekend course? Well, those damn whippersnappers from Oregon are putting the non-believers to shame.

Medicine interns at Oregon Health & Science University were taught point of care ultrasound 3 months into their first year, as one day of a 5 day medical “boot-camp.” The day-long program consisted of 15-20 minutes of didactic training, and was followed by a 40 minute hands on session. Learners were placed in groups of 2-3 individuals and taught one-hour modules consisting of: the basics (knobology, physics, etc), CLUE protocol, FAST exam, hydronephrosis eval, and aorta & neck anatomy.  The 40 minute hands on portion was divided into 20 minutes for completing modules demonstrating pathology on SonoSim machines and 20 min for facilitator-led hands-on practice with volunteer models. (example- 20 didactic minutes learning FAST, 20 minutes on simulation, then 20 minutes on a real-live person!).  This was followed by two optional 1 hour courses done within 6 months.

A 30 question multiple choice test was administered prior to the course to all 33 interns, testing image interpretation, image acquisition/optimization, and clinical applications of ultrasound. The test was re-administered 6 months later; there was a significant drop out rate (27%), and it was untracked as to whom took the optional one hour courses.

Survey says?

Mean pretest scores – 61%

Mean post-test scores- 85%

Mean 6 month post-test scores – 79%

Great news – We probably intuitively know & retain much more than we think, but just have to continue to pick up the probe to hone our craft.  Bad news, I’m not certain that an ability to retain enough knowledge to improve a multiple choice test score is the same as making a correct clinical decision off of limited ultrasound skills.  Admittedly, POCUS in the wrong hands can be a problem, and making clinical decisions based off limited ultrasound skills and knowledge is a difficult leap to take, but its one we invariably have to make in order to grow as a clinician.

So, yeah, don’t tell me you can’t learn ultrasound.

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Improving Throughput, Mythbusting, Radiology, Radiology

Sono-guided Right IJ? Skip the chest film.

1,322 sono guided IJ central lines. Guess how many pneumothoraces.

One. Exactly one.

Overall success rate – 96.9%.

One percent of the time the catheter required repositioning. So, basically a failed rate of 2%.

Zero arterial placements.

Sure, 1,322 over a one year period is insanity (Henry Ford in Detroit, if you’re curious), and you can easily argue that a hospital that places that many central lines probably has it down cold.

Bottom line, if you are competent enough to place an ultrasound guided right sided IJ central line, you can skip the xray, especially if it is going to delay care. You do not image your femoral lines before usage, do you?

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Improving Throughput, Mythbusting, Radiology

Distracting Injuries & the Pan-Scan

So, what is really distracting? According to NEXUS (multiple links here), it is any long bone fracture, visceral injury requiring surgical consultation, lacs >10cm, degloving injuries, crush injuries, large burns, or anything causing functional impairment. Do these requirements dictate the need for head CT as well?

In the ongoing debate of EM vs Trauma for selective imaging, comes this paper.  From April 2014 – September 2014, the authors looked at 330 patients with mild TBI (GCS 13 or higher), to determine if distracting injuries were truly an indication for head CT. Patients were excluded if 18 months or younger of age, over age 60, moderate/severe or progressive headache, 2 or more episodes of vomiting, +LOC, amnesia, seizure or antiepileptic use, intoxication, uncontrolled hypertension, anticoagulated, had a neurologic deficit, penetrating injury, or craniofacial deformity.

Of 184 patients with fractures & severe pain (90 lower limb, 56 upper limb, 36 thoracolumbar, and 2 pelvis fractures – note there were NO cervical fractures noted), 2 (1.1%) had brain edema on CT, while of the 146 patients with no fractures/dislocations and no/mild pain, only 1 (0.7%) had brain edema on CT. No patient in any group had any neurologic symptoms at 1 month or 3 month follow up.

For many of us, this confirms our practice.  Please share with your pan-scanning colleagues.

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"Palliative" is not a dirty word, GI, Improving Outcomes, Improving Throughput, Mythbusting, Radiology

Versed, Pavlov, & the NGT

I admire & strive for efficiency, empathy, and efficacy.  Thus, if a certain painful procedure extends lengths of stay without significant benefit to the patient, I’m hesitant to order it. However, sometimes it is frowned upon to not play nice in the sandbox with our Pavlov consultants who request NG tubes for small bowel obstructions.

5118101

 

Thus, if you must place an NG tube for an obstruction, keep today’s study in mind.

Up at The U (of Vermont), patients that were ordered an NG tube and were between 18 and 60 years of age were given 1 ml of intranasal atomized co-phenylcaine (lidocaine 5% with 0.5% phenylephrine to each nostril, followed by either placebo or 2 mg of IV midazolam with NG tube placement within 5 minutes of placebo or midazolam. Using a 100 mm VAS for pain and discomfort, as the primary endpoint, the patients were interviewed 15 or 45 minutes after the procedure.

After 51 total cases (23 of which qualified for the study), the trial was stopped early as several ED clinicians felt that midazolam prior to insertion was superior to topical anesthetics alone and did not want their patients randomized in the study.

Hence, the numbers are a good bit low. Only 13 patients in the control arm, and 10 in the treatment arm. The mean difference in pain scores was 31mm and 36mm for discomfort. None of the midazolam placements were rated difficult by nursing who placed the NG tube, whereas 3/13 in the control group were rated as difficult or very difficult to place.

So yes. The numbers are small, and the authors shed some light on questions we would have. They spoke about anecdotally about 1mg of midazolam for those over 60 years old or with known pulmonary disease – which they felt did not alleviate pain or discomfort. Here, I think a 1mg bolus followed by 0.5mg boluses as needed is reasonable.

They cite a paper stating that 91% of providers would change their practice if new literature showed a convenient way to reduce patient discomfort. Well, here it is. So, if Pavlov’s dog barks and you HAVE to place an NG tube, hopefully your institutional policy allows IV midazolam without considering it procedural sedation (or, potentially using intranasal midazolam for anxiolysis).

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

POCUS, Aneurysms, and Mortality Rates.

If you’re a #FOAM follower, you have probably seen the pleas for bedside ultrasound more than once. This paper takes an interesting approach to try and demonstrate its value in the diagnosis of aortic dissection: Over a two year period and 386,547 patient visits, there was a review of 123 medical reports and 194 autopsy reports, of which 32 patients were identified for inclusion. 16 received EP POCUS, 16 did not.

Median time to diagnosis – 80 minutes in the POCUS group vs 226 minutes in the non POCUS group. Misdiagnosis was 0% in the POCUS.

Mortality adjusted for DNR status: 15.4% vs 37.5%, POCUS vs non-POCUS.

Time to dispo? 134 minutes vs 205 minutes, POCUS vs non-POCUS. (and probably a much greater difference in time to *appropriate* disposition.)

[note that neither mortality or time to dispo was statistically significant] 

With that said, I agree with the authors conclusions, (particularly in light of this previous post): “Patients who receive EP FOCUS are diagnosed faster and misdiagnosed less compared with patients who do not receive EP FOCUS. We recommend assessment of the thoracic aorta be performed routinely during cardiac ultrasound in the emergency department.”

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Improving Outcomes, Improving Throughput, Mythbusting, Neurology, Neurology, Radiology, Radiology

Community EM rejoice- CT within 6 hours safe for SAH rule out.

There is yet another paper to further elucidate who should get the CT / LP work up for subarachnoids. The authors looked at six EDs over 5 years, and encompassed 2,248 patients – of which 1898 had suitable LPs for analysis (insufficient sample, exposed to light [?], blood contamination, incorrect storage or transport [?], or they just plain lost the sample). CT reads were done by on-call radiologists in training (I imagine that means residents), or by board-certified radiologists. Images were then reviewed by a board-certified neuro-radiologist OR by a board-certified general radiologist for a final report. There was no “time limit” from onset of headache for exclusion (ie, patients did not need to be scanned within six hours).

92 patients of the 1898 patients were positive for blood via spectrophotometry – 4.8%. Nine of these positives ended up having a subarachnoid hemorrhage (9.8% of their LPs, or 0.47% of patients). What do these nine patients generally have in common? Six of them had a headache for a week or longer. One had a previously coiled embolism. One had a negative CT performed within 3 hours of onset.  All of these nine patients got coiled or clipped.

So, what do we make of these? If you present within 6 hours with a negative CT (or, dare I say, less than a week!), you have a 0.053% of having a subarachnoid. If you still do the LP in those <6hours from onset (or, <1 week from onset), the baseline risk of a false positive is 10% vs 1.1% chance of true SAH.

Time for some well-informed shared decision making, and perhaps a higher threshold for those that present with a prolonged headache.  Further good news to take away from this study- it does not seem as neuro-radiologists need to make the call and that the <6 hour proposal can be safely extended to the community setting at this point.

 

(First link is to free text of article.  Pubmed did not have a working link to the paper at time of post.  If the first link does not work, try here)

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