Category Archives: Literature Reviews

ACEP’s Choosing Wisely campaign

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Here’s an excerpt from our ED-Public Health website (http://www.edpublichealth.com):

ACEP’s contributions to the Choosing Wisely Campaign

At ACEP13 last October in Seattle, the organization announced its 5 contributions to the Choosing Wisely Campaign. Initially started by the American Board of Internal Medicine (ABIM) Foundation, the Choosing Wisely Campaign was a response to the movement towards improved healthcare efficiency and a need to decrease unnecessary/low-value procedures and tests. Despite ACEP’s original reluctance to join, in February 2013 ACEP jumped on board and began creating their list of recommendations. After extensive review by an expert panel of emergency physicians and the ACEP Board of Directors, ACEP’s Choosing Wisely recommendations were released.1,2 They include:

1. Avoid Head CTs in ED patients with minor head injury who are at low risk based on validated decision rules.
2. Avoid placing indwelling urinary catheters in the ED for either urine output monitoring in stable patients who can void, or for patient or staff convenience.
3. Don’t delay engaging available palliative and hospice care services in the ED for patients likely to benefit.
4. Avoid antibiotics and wound cultures in ED patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up.
5. Avoid instituting IV fluids before doing a trial of oral rehydration therapy in uncomplicated ED cases of mild or moderate dehydration in children.

You be the judge.
Here is a list of pros and cons formulated based on literature review, articles and editorials from other emergency physicians (EPs).

Pros:
1. Reduce cost without affecting quality of care.1,2
2. Improve efficiency.1,2 Example: shorter LOS if imaging is involved
3. Encourages shared decision-making between patients and physicians.1,2,8
4. Medical benefits: Less ionizing radiation exposure, less risk of antibiotic-resistant organisms, fewer catheter-associated UTIs.1,2,4
5. EP-generated, EP-approved. EPs are identifying “low value” procedures/tests for their own speciality, rather than letting others define these for us.1,2,6 For example: the proposed, but ultimately rejected, CMS “use of Brain CT in the ED for atraumatic headache” measure was created by CMS without EP input.8

Cons:
1. Lack of advocacy for medical liability reform.1,2,5
2. EPs have no right of refusal to our patients.5
3. EPs often pick up the slack for other doctors.5
4. Will it come to a point where these 5 tests/procedures will be uncompensated?5
5. Loss of autonomy.6

Other lists of over-used and “low value” tests exist out there. Most notable is a list of 5 tests which was created by EPs and mid-level providers from six Partners Healthcare hospitals near Boston. Published in JAMA, this list was designed to be “actions a specialty provider”7 can take.6,7 They include:

1. Do not order CT of the C-spine for patients after trauma who do not meet NEXUS low risk criteria or the Canadian C-spine Rule.
2. Do not order CT to diagnose PE without first risk stratifying for PE (pretest probability and D-dimer tests if low probability). (included in ACR’s Choosing Wisely list)3,4
3. Do not order MRI of the L-spine for patients with lower back pain without high-risk features. (included in AAFP’s and ACP’s Choosing Wisely list)3,4
4. Do not order CT of the Head for patients with mild traumatic head injury who do not meet New Orleans criteria and Canadian CT Head Rule.
5. Do not order coagulation studies on patients without hemorrhage or suspected coagulopathy (eg: with anticoagulation therapy, clinical coagulopathy)

ACR = American College of Radiology, AAFP = American Academy of Family Physicians, ACP = American College of Physicians

Bedside actions: to begin incorporating these EP-approved recommendations into our daily practice in an effort to institute cost-effective quality medical care (ideally before private insurers, CMS, or other specialty societies begin mandating us to do the same)

References:
1. ACEP Announces List of Tests as Part of Choosing Wisely Campaign. ACEP Clinical & Practice Management. October 14, 2013. Downloaded from http://www.acep.org/Clinical—Practice-Management/ACEP-Announces-List-of-Tests-As-Part-of-Choosing-Wisely-Campaign/.
2. ACEP Prepares List for Choosing Wisely Campaign. ACEP Clinical & Practice Management. Downloaded from http://www.acep.org/Clinical—Practice-Management/ACEP-Announces-List-of-Tests-As-Part-of-Choosing-Wisely-Campaign/.
3. Choosing Wisely Master List. www.choosingwisely.org. Downloaded from http://www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf.
4. Mahesh, M. and Durand, D.J. The Choosing Wisely Campaign and its Potential Impact on Diagnostic Radiation Burden. J Am Coll Radiol. 2013; 10(1): 65-6.
5. Seaberg, David. Pro/Con: Why ACEP Should Not Join the ‘Choosing Wisely’ Campaign. Emergency Physicians Monthly. Published August 24, 2012. Downloaded from http://www.epmonthly.com/features/current-features/the-wiser-choice-should-acep-join-the-choosing-wisely-campaign-no/.
6. Schuur, J.D., Carney, D.P., Lyn, E.T., Raja, A.S., Michael, J.A., Ross, N.G., and Venkatesh, A.K. A Top-Five List of Emergency Medicine: A pilot project to improve the value of emergency care. JAMA Intern Med. 2014; 174(4): 509-515.
7. The Tale of Two Lists: Procedures to Avoid in the ED. Acute Care, Inc. Published February 25, 2014. Downloaded from http://www.acutecare.com/the-tale-of-two-lists-procedures-to-avoid-in-the-ed.
8. Venkatesh, A.K. and Schuur, J.D. A “Top Five” list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care. American Journal of Emergency Medicine. 31 (2013) 1520-1524.

 

Acute Cardiogenic Pulmonary Edema

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Here is nice summary post by FOAMed guru Anand Swaminathan with evidence-based discussion of the role (or lack thereof) for diuretics in acute pulmonary edema. Trust me it works. See also the first Emcrit podcast on the topic.

Bottom line: minimal role for diuretics in the pulmonary edema patient in extremis. This is not the mildly fluid overloaded patient with normal respiratory status, they can use a little diuresis once BUN/Cr are determined.

Routine Coags in Chest Pain

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Thought this was a great little post regarding Coagulation studies in chest pain patients. Not sure how often its getting routinely obtained on our CP patients @ UofL but at Norton they get it on almost every chest pain patient that rolls through the door.
We’ve reduced the amount of coag studies we’re getting on our routine trauma patients, probably about time we make sure we’re doing the same in our low-risk chest pain patients.

What Emergency Physicians Can Do to Reduce Unnecessary Coagulation Testing in Patients with Chest Pain

Burnout

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Brief description of burnout types. Not medically specific. Follow the links as well.

1. Overload: The frenetic employee who works toward success until exhaustion, is most closely related to emotional venting. These individuals might try to cope with their stress by complaining about the organizational hierarchy at work, feeling as though it imposes limits on their goals and ambitions. That coping strategy, unsurprisingly, seems to lead to a stress overload and a tendency to throw in the towel.

2. Lack of Development: Most closely associated with an avoidance coping strategy. These under-challenged workers tend to manage stress by distancing themselves from work, a strategy that leads to depersonalization and cynicism — a harbinger for burning out and packing up shop.

3. Neglect: Seems to stem from a coping strategy based on giving up in the face of stress. Even though these individuals want to achieve a certain goal, they lack the motivation to plow through barriers to get to it.

In a roundup of 11 ways to beat burnout, 99u offers this breakdown of the three main types of burnout, per the Association for Psychological Science.

Pair with this essential read on how to transcend the “OK plateau” of work, then see how sleep factors into the equation.

Here is the article itself from APS.

 

 

Reference:

http://explore.noodle.org/post/83726976259/1-overload-the-frenetic-employee-who-works?utm_content=bufferef345&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

The Hypercoagulable Liver Failure Patient?

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Hey Guys,
Just listened to a portion of April EM:RAP (so if you’ve heard it already here’s a little repetition) and was surprised to hear their Notes from the Community Section about coagulopathy in Liver Disease, which basically informed me that many liver patients are at just a high of risk of thrombosis as they are of bleeding.

3 Articles were referenced:
– Tripodi A, Mannucci PM. The coagulopathy of chronic
liver disease. N Engl J Med. 2011 Jul 14;365(2):147-56.
– Villanueva C et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3;368(1):11-21.
– DeLoughery TG et al. Invasive line placement in critically ill patients: do hemostatic defects matter? Transfusion. 1996 Sep;36(9):827-31.

Summary:
– The liver makes both procoagulant and anti-coagulant proteins which can be actually reduced close to equally rendering the patient basically in equilibrium (thus not so hypercoagulable).
– No study has shown that coagulation defects predict issues with procedures (but the experience of the clinician performing the procedure does).
– INR is not standardized in Liver Failure patients (like it is with Warfarin) and thus is not that helpful.
– PT & PTT may also not be helpful in patients with liver failure (due to the variability of loss of clotting factors)
**Fibrinogen may be low in liver failure patients, and you may consider replacement of this with Cryoprecipitate (10 units of Cryo increases the Fibrinogen by 100mg/dl).
– Raising intravascular volume with pRBCs may make them bleed more.

For the full references & discussion see the EM:RAP written summary. Perhaps this is something we should discuss with our GI colleagues and/or MICU people. Any thoughts?

March EM:RAP Summary

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EMRAP_2014_03_March_3.1.14[1]

Hey Guys,
Just some things I learned on EM:RAP this month, and since I’m on admin thought I would post a few things.

The DRE (not the rapper Dr. Dre): from the Fingers & Foley’s section on EM:RAP; reviewed Esposito TJ et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma. 2005. They had 512 trauma patients at a Level I Trauma Center. “the negative predictive value of both the rectal exam and other clinical indicators was very high: 99%. However if the other clinical indicators missed the injury, so did the rectal exam. It didn’t add any information”
Basically showed added value of a rectal exam to be very minimal, and that ROUTINE RECTAL EXAM IS NOT RECOMMENDED. BTW, this is in the journal of trauma which is well-regarded amongst our surgery friends.

How to identify if patient’s contact lens is still in the eye (e.g. if patient has eye pain and feels like its still in there and can’t find it): Use Fluorescein much like you would for corneal abrasion as it will stain the contact lens as well, allowing you to find it (then you can evaluate for corneal abrasion at the same time). *keep in mind contact lens will be ruined*

Subarachnoid Hemorrhage: from an article in JAMA in Sept 2013 with 10 university affiliated Canadian EDs. Tried to come up with a decision rule for SAH and basically came up with:
The decision rule including any of age 40 years or older, neck pain or stiffness, witnessed loss of consciousness, or onset during exertion had 98.5% (95% CI, 94.6%-99.6%) sensitivity and 27.5% (95% CI, 25.6%-29.5%) specificity for SAH. Adding “thunderclap headache” (ie, instantly peaking pain) and “limited neck flexion on examination” resulted in the Ottawa SAH Rule, with 100% (95% CI, 97.2%-100.0%) sensitivity and 15.3% (95% CI, 13.8%-16.9%) specificity.
**Key points: this decision rule is more to identify high risk patients and the high risk symptoms. Sensitivity was very high, but specificity very low. Also keep in mind there are other important causes of headache to keep in mind**

Biphasic Reactions in Anaphylaxis: from Annals of Emergency Medicine in November 2013. A chart review was performed over 5 years and had ~500 pts with anaphylaxis, but also documented allergic reactions. Found biphasic reaction was extremely rare (2 cases while in the ED, and 3 out of the ED), with a rate of 0.4% while in the ED. 6% bouncebacks in the anaphylaxis group, none of which died and none of which came back in anaphylaxis. This study was limited in that it was retrospective, and there was variability in the outpatient management of these patients (unclear who was DC’d with what if any medications)
Rosen’s states corticosteroids can be helpful in reducing risks of protracted anaphylactic reaction and biphasic anaphylaxis (7-10 day course). H1 & H2 antihistamines are helpful in reducing some of the symptoms of anaphylaxis. 5-Minute Emerg Consult recommends Epi-Pen for those with anaphylaxis.
No Formal observation time has been established, though Rosen’s says 2-6 hours; with longer observation times/admission for those with prolonged reaction or requiring multiple dose epinephrine

Sorry this is so long, but I’m on Admin so thought I’d post something. Attached you’ll find the March Written Summary with all the articles they referenced. Hope this is helpful.