Cardiology, Improving Outcomes, Mythbusting

SVT: treat, wait, re-evaluate

What do you *really* need to do with your SVT patients? Well, this is a retrospective observational study of 633 consecutive SVT patients over 10 years seen in a single ED. This was more hypothesis generating than anything – they basically provide patient characteristics and try to tease out if labs / imaging were necessary.

Their mean age was 55, 62% of patients were female, 55% had prior SVT history, 31% had at least one cardiovascular risk factors (dyslipidemia, hypertension, diabetes, CHF, or vascular disease), and 9% had ischemic heart disease.

Some interesting lab nuggets:

-0.4% had a hemoglobin < 8g/L

-1.5% had a sodium >150 mmol/L, none <126

-no patient with severe hyperthyroidism

Chest Xray was obtained 30% of the time, and while it was abnormal 21.6% of the time (41 of 190), none of the time did it alter ED treatment – despite showing 14 cases of pulmonary edema, 4 cases of pneumonia, and 3 pleural effusions.

The authors conclude that patients with uncomplicated SVT are over-investigated, and that most have normal or near-normal results. While I tend to agree – for the 25 year old in SVT without a concerning story – the 55 year old diaphoretic (14% were diaphoretic) female with ischemic heart disease I’m going to work up. Chest films were only ordered on 30% of these patients – frankly in a US hospital, I’m thankful its not higher.

I know Billy Mallon loves his TSH, but why not get a better history to see if there are other concerning symptoms before sending off TSH… Speaking of which, maybe we could decrease those Chest films if we fixed the patient a bit, then reassessed to see if imaging is wanted. (ie, are you still short of breath?).

Finally, I think this study is plagued by premature closure, as they only searched for cases with a discharge diagnosis of paroxysmal supraventricular tachycardia. They’re likely missing at least a few patients who came in with SVT and were found to have actually have another diagnosis.

Ultimately, while this study should not change practice by any means, it should give us pause before shotgunning labs & chest films until after we treat the patient, re-evaluate, and get a better history. This could probably be said for many other diagnoses besides SVT.

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Mythbusting

Let’s stop the sepsis high-five.

82 y/o F from SNF, AMS, “foul smelling urine.”

80/50, 103.1 PR, 120HR 98%.

An initial POCUS showed a collapsing IVC, you give 30 cc/kg LR, 650 Tylenol PR, vancomycin loading dose, and 3.375g Zosyn. BP is now 110/74, HR is 80 bpm, labs show an obvious UTI, and you call to admit the patient.

Or as I like to call this, the “sepsis-high five.”

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This is a single center study of 828 patients looking at time delay between first and second antibiotic. They broke it down to 6, 8, 12, and 24 hour drugs, and considered a delay of 25% significant (90 minutes for a q6 hour drug, 180 minutes for a BID drug, etc). The primary outcome being in-hospital mortality.

So what’d they find? Well, unsurprisingly, they found that 72% of patients had a delay with 6hr dosing between their first dose and second dose compared to 47% for Q8hr antibiotics, and 25% for Q12hr antibiotics. (<5% for Q24hr drugs- but they had 6 hours to hang the dang drug!)… They acknowledge several issues: we often order a one time dose in the ED, but the upstairs care only knows Q6hr drugs at 12-6-12-6 dosing. I think this is most likely the case in this study, since the next dose for a 6, 8, and 12 hour drug were 9.55, 9.6, and 10.6hr respectively. They also acknowledge that it is possible that delayed second antibiotics are not inherently contributory to adverse patient outcomes, but simply a surrogate for patients who generally received less attention and care overall, particularly given 43% of delays occurred in ED boarding in their institute.

Paradoxically, those that received the q6hour antibiotic (cough, ZoSyn, cough), had high rates of adherence to the sepsis bundle (fluid loading, early pressors, early abx, etc) – but also high rates of >25% delays to second doses. True, it only took an hour and a half to have a delay for zosyn, but that is the point here: while yes, you provided solid care up front, are your system failures (preset administration times from your inpatient order sets) hurting your patients? Or is it a sign that those getting tighter adherence to everything (Q6hr drugs, early pressors, etc), and that those patients are getting better care with better adherence to second dose antibiotics as merely a proxy?

Regardless, there was a 1.6x increased odds of mortality for those with >25% delay, and a 2.4x high rate of mechanical ventilation, with an OR of 72 for a missed second dose of a q 6hr drug, 24 for a q 8hr drug, and 7 for a q 12hr drug.

Call it better care. Call it a reason to do a ZoSyn continuous infusion. Call it an inpatient problem. Regardless, it should not be ignored.

Me? I maintain that if the patient is still in my emergency department, its still my patient no matter how long they have been there. Hence, I’ve been known to periodically order a second dose of ZoSyn – especially for the critically ill and those being transferred. So, much like after a successful intubation post-arrest there is much work to do, there is much work to do post resuscitation for a septic patient.

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Mythbusting

Dedicated post-arrest services? meh.

Should we regionalize post-arrest care?  Well, if your facility does not have a cath lab, then the answer is yes.  But Academic Hospital A, which sees >100 arrests a year, just started advertising a fancy post-cardiac-arrest service.  Academic Hospital B also sees >100 arrests a year, but does not have a post-arrest service aside from their MICU.

You, being at hospital C without a cath lab, have just achieved ROSC in a witnessed arrest. Who do you transfer to?

This study looks at 987 post-arrest patients that survived to admission at 7 hospitals in and around Southwestern Pennsylvania. One of them is a regional referral center with post cardiac arrest services consulted on OHCA with ROSC, accepts sudden cardiac arrests from outside facilities, and is consulted on in-hospital arrests with ROSC. There are two additional tertiary care centers that see >100 SCA annually, and 4 “low volume” centers. They look at multiple variables, and evaluate discharge disposition, discharge CPC, and length of survival post-discharge.

They improved numbers of discharge CPC – the post arrest service center with a discharge CPC of 1 or 2 32% of the time vs 37% of the time for the other 6 facilities. More patients were discharged to home (41% vs 32%) from the post-arrest service center and survived for longer if they were treated with the post-arrest service.

Now….

While the authors claim similar patient characteristics between the post-arrest service center and the other 6 hospitals…. 46% of patients were transferred to the post-arrest service center vs 16% at hospitals 2-7 – perhaps skimming a healthier patient that made it through the transfer (remember- you had to survive to discharge to be counted) – the authors even acknowledge that their transferred patients did better than their other arrests.

Add in that the initial rhythm 51% of the time was VT/VF for the post-arrest service center vs 41% in the other six hospitals, and you’ve got plenty of confounders. Frankly, given all of this, it’s a bit strange that the proportion of patients surviving to discharge did not differ at all. One would think if you have a post arrest service and the scales are tipped in your favor to begin with, that you’d have a higher percentage of patients surviving.

Ultimately, patients lived longer post-arrest when treated at a facility with a post-arrest service, and the authors are touting this as reason to (further) regionalize post-arrest care.  Sure, there are slightly better neurologic outcomes, but the scales were tipped in their favor to begin with. I don’t trust this conclusion, especially when the post-arrest service had an advantageous patient population to begin with that should have led to a measurable increase in improved survival, in addition to an increase in length of survival.

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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 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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Mythbusting

PA’s- making Ada Plumer Proud.

Many years ago, nursing was not allowed to place IVs. Now, in some places, they place ultrasound guided PICCs, and in a handful of places, ultrasound guided central lines.   Nursing can titrate vasopressors, and in some facilities, they run ACLS during codes.

 

So…. Have you ever experienced or asked “for the doctor (or consultant)?”

Have you ever been concerned and wondered do PA’s provide appropriate care in the ED?

This study is done at the world famous Our Lady of Lourdes in Camden,NJ, with none other than the EM famous Al Sacchetti- and should aim to answer some of these concerns, at least in the pediatric population

Over a 24 month period, over 10,000 patients age 6 or younger were restrospectively evaluated for bounce back rates and broken down into 3 groups based on their provider: attending only care, PA only care, or co-evaluation by both EP and PA.  Here’s the twist- in this department, policy permits PA’s to evaluate treat and discharge patients of any age independent of the attending physician.  There are no specific protocols for assigning specific patients to specific providers, though they do state that PA’s do not perform LP’s in the study department, and that febrile infants <8 weeks were brought to the immediate attention of the attending physician by the triage nurse.  Essentially, the PA seemingly functions at a high level and fairly autonomous.

So what’d they find?  Are you more likely to “bounceback” based on who you’re seen by?

Well, as one would likely expect, a higher percentage of higher acuity patients were seen by the attending physician (85% ESI-2, 70% ESI-3, 60% ESI 4/5.), and the younger the patient, the more likely they were an “attending only” case.

Bounce backs?  Only 0.4% of PA only cases vs 0.6% of attending only cases bounced back and were admitted – not statistically significant – and below the national average of 0.83%.  Only 0.9% of PA only cases were admitted vs 4.1% of attending only cases (and 3.4% of PA/MD cases.  This was statistically significant, and likely reflects higher acuity of the cases the MD is involved in.  There was a higher rate of return visits in MD only cases – 8% vs 6.8% (statistically significant) – but the rate of return for combined MD/PA cases was highest – 9.3%.

Amongst ESI 2,3, & 4s, bounceback rates for EP only eval was consistently higher than PA only eval, and bounceback rates for MD/PA co-evaluation was consistently higher than both PA only and MD only eval.

So, what’s the take home?  For one, its that PA’s can provide high level care without a significant drop off in care… and that in order for medicine to progress, we have to cognitively offload to expand our boundaries.  This may include expanding services to nursing or PAs (as discussed above)…

And here is the most important message:

Dont be that person – if someone (nursing, PCA’s, PA/NP’s, etc) comes to you with a concern – go see a patient.  We’re all on the same team.  Take it as a compliment – as evidenced by this paper it’s likely a complex or clinically ambiguous case with a higher bounceback rate, and who doesnt like a challenge!

 

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