Quality – Page 15 – Emergency Medicine Literature of Note

Critical Deficiencies in Pediatric EM Training

This article is an overview of the critical procedures performed over a one-year period at Cincinnati Children’s, a large, well-respected, level 1 trauma center with a pediatric emergency medicine fellowship program. In theory, this facility ought to provide trainees with top-flight training, including adequate exposure to critical life-saving procedures.

Not exactly.

In that one year period, the PEM fellows performed 32 intubations, 7 intraosseus line placements, 3 tube thoracostomies, and zero central line placements. This accounted for approximately 25% of all available procedures – attending physicians and residents poached the remainder of procedures during the year. Therefore, based on this observational data, these authors conclude the training in PEM might not be sufficient to provide adequate procedural expertise. Then, the authors note pediatric emergency departments have such routinely low acuity – 2.5 out of every 1,000 patients requiring critical resuscitation – that it is inevitable these skills will deteriorate.

Essentially, this means the general level of emergency physician preparedness for a critically ill child is very low. PEM folks might have more pediatric-specific experience – but very limited procedural exposure – while general emergency physicians perform procedures far more frequently – but on adults. The authors even specifically note 63% of PEM faculty did not perform a single successful intubation throughout the entire year.

Their solution – which I tend to agree with – is the development of high-quality simulation tools to be used for training and maintenance of skills. Otherwise, we won’t be providing optimal care to the few critically ill children who do arrive.

“The Spectrum and Frequency of Critical Procedures Performed in a Pediatric Emergency Department: Implications of a Provider-Level View”
www.ncbi.nlm.nih.gov/pubmed/22841174

The Boondoggle of Step 2 CS

Recent medical school graduates are familiar with the Step 2 Clinical Skills examination, a day-long charade of simulated clinical encounters intended to screen out medical students who are incapable of functioning in a clinical setting. This test was adapted from the ECFMG Clinical Skills Assessment, intended essentially to screen out foreign medical graduates with inadequate communication skills to safely practice medicine in the United States.

However, U.S. and Canadian medical school graduates pass this test 98% of the time on the first attempt, and 91% of the time on a re-attempt. This means each year $20.4 million are expended in test fees – and probably half again that amount in travel expenses – to identify 30-odd medical school graduates who are truly non-functional. The authors of this brief letter in the NEJM suggest, with interest compounding secondary to medical school debt repayments, it costs over a million dollars per failed student.

Clearly, some medical students are not capable of functioning as physicians. However, clinical skills teaching, evaluation, and remediation ought to be part of the purview of the medical school training program that has multi-year longitudinal experience with the student, not a one-day simulation. I’m sure some of the few who fail Step 2 CS twice are capable of safely practicing medicine, and certainly many who pass Step 2 CS still require additional teaching. I agree with these authors that this test is an expensive and ineffective farce.

Then again, as this NYTimes vignette points out, medical schools are having a tough time failing folks for poor clinical skills. However, the solution is not to pass the buck along to the NBME.

“The Step 2 Clinical Skills Exam — A Poor Value Proposition”
www.nejm.org/doi/full/10.1056/NEJMp1213760

EM Lit of Note on KevinMD.com

Featured today as a guest blog, revisiting the JAMA Clinical Evidence synopsis critiqued last month on this blog, here and here.

It’s rather an experiment in discovering just how influential social media has become – open access, crowdsourced “peer review” – and whether this mechanism for addressing conflict-of-interest in the prominent medical journals is more effective than simply attempting a letter to the editor.

KevinMD.com – “The filtering of medical evidence has clearly failed“

The Sad Reality of Chest Pain Observations

Chest pain observation units run by the Emergency Department are fairly popular – and it’s easy to see why. It eliminates the need to fight a hospitalist for admission, allows for complete coverage of medicolegal liability, captures another set of billing codes for ED revenue, and keeps the cardiologists happy with a steady stream of interpretation and consultation revenue.

Duke University has one of these such chest pain observation units, and this study is a retrospective evaluation of the subgroup of patients aged less than 40 years. Of the 2,231 patients observed for suspected acute coronary syndrome, 362 met eligibility based on age. Of these 362 patients, median age 36, 238 underwent stress testing and the remainder underwent serial enzymes.

From this cohort, there was a single true positive – defined as a patient who underwent a coronary angiogram with an intervention performed.

There were, however, 14 false positives – indeterminate or positive stress tests and one set of positive biomarkers, leading to five negative invasive coronary angiograms.

The authors sum it up quite nicely: “The extremely risk- adverse physician cannot totally exclude the possibility of ACS based on age, but it seems that routine observation for such patients may cause the potential for as much harm as good.”

“Utility of Observation Units For Young Emergency Department Chest Pain Patients”
www.ncbi.nlm.nih.gov/pubmed/22975283

Informatics for Wrong-Patient Ordering

It seems intuitive – if, perhaps, the electronic health record has an updated problem list, and the EHR knows the typical indication of various medications, then the EHR would be able to perform some cursory checks for concordance. If the orders and the problems are not concordant – then, as these authors propose, perhaps the orders are on the wrong patient?

This study is a retrospective analysis of the authors’ EHR, in which they had previously implemented alerts of this fashion in the interests of identifying problem lists that were not current. However, after data mining their 127,320 alerts over a 6-year period, they noticed 32 orders in which the order was immediately cancelled on one patient and re-ordered on another. They then conclude that their problem list alert also has the beneficial side-effect of catching wrong-patient orders.

A bit of a stretch – but, it’s an interesting application of surveillance intelligence. The good news is, at least, that their problem list intervention is successful (pubmed) – because a 0.25 in 1000 patient alert yield for wrong-patient orders would be abysmal!

“Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE)”
www.ncbi.nlm.nih.gov/pubmed/23396543

Pooled CCTA Outcomes

The state of the art for coronary CT angiograms progressed a great deal in the past year. Four recent studies, CT-STAT, ACRIN-PA, ROMICAT II, and a fourth by Goldstein et al., have added to our knowledge base regarding the performance characteristics of this test.

Overall, by pooling 3,266 patients from these four trials, a couple new features shake out as statistically significant. Specifically, patients undergoing CCTA were significantly more likely (6.3% vs 8.4%) to undergo ICA, and then more likely to receive revascularization (2.6% vs. 4.6%). This adds to what we already knew – CCTA shortens ED length of stay and reduces overall ED costs compared with “usual care”.

But, we still don’t really know if this test is improving important patient-oriented outcomes. These intervention numbers are quite low – meaning a great number of patients simply received expensive diagnostic testing, without any sort of treatment. Then, we don’t even know if these revascularizations are improving (or worsening!) outcomes. Technology keeps blundering forward with its flawed disconnect from rationality – the costs go up and up, but we don’t hardly stop to measure whether we’re actually doing any good….

“Outcomes After Coronary Computed Tomography Angiography in the Emergency Department”
content.onlinejacc.org/article.aspx?articleID=1569168

Copy & Paste Medicine

Mostly unrelated to Emergency Medicine – but an interesting descriptive study of a downstream phenomenon I see on a frequent basis.

For example, I’ll intermittently follow-up a patient to see how they fared as an inpatient. I’ll read the inpatient documentation, consultant reports, etc. – and find the tiny EM HPI perpetuated throughout the chart with minimal modification. This anecdotal experience is backed up by these authors who used text-compare software to identify copied passages in daily progress notes from an ICU setting. In this ICU at MetroHealth in Cleveland, 82% of resident notes copied at least >20% of the text from the previous days’ progress note – and copied 55% of the prior content on average. Attending notes were slightly less frequently copied (74%), but tended to copy more content (61%).

There’s no conclusive data regarding whether this copy/paste practice affects patient outcomes, but it’s an interesting symptom of evolving medical care and documentation in the EHR era. I hope that, as HIT evolves, documentation tools trend towards encouraging concise, effective communication, rather than this sort of (likely ineffective) chart bloat.

“Prevalence of Copied Information by Attendings and Residents in Critical Care Progress Notes”
www.ncbi.nlm.nih.gov/pubmed/23263617

What Are “Trustworthy” Clinical Guidelines?

This short article from JAMA and corresponding study from Archives is concerned with advising practicing clinicians on how to identify which clinical guidelines are “trustworthy”. This is a problem – because most aren’t.

The JAMA article paraphrases the eight critical elements in the 2008 Institute of Medicine report required to generate a “trustworthy” article, such as systematic methodology, appropriate stakeholders, etc. Most prominently, however, several deal specifically with transparency, including this paraphrased bullet point:

Conflicts of interest: Potential guideline development group members should declare conflicts. None, or at most a small minority, should have conflicts, including services from which a clinician derives a substantial proportion of income. The chair and co-chair should not have conflicts. Eliminate financial ties that create conflicts.

The Archives article cited by the JAMA article reviews over 100 published guidelines for compliance with the IOM. The worst performance, by far, was compliance with conflicts of interest, and notes that 71% of committee chairpersons and 90.5% of committee co-chairpersons declared COI – when declarations were explicitly stated at all. Overall, less than half of clinical guidelines met more than half of the IOM recommendations for “trustworthiness”.

Sadly, another dismal addition to the all-too-frequent narrative describing the rotten foundation of modern medical practice.

“How to Decide Whether a Clinical Practice Guideline Is Trustworthy”
www.ncbi.nlm.nih.gov/pubmed/23299601

“Failure of Clinical Practice Guidelines to Meet Institute of Medicine Standards”
www.ncbi.nlm.nih.gov/pubmed/23089902

Inadequate “Overuse” Reduction Strategies

This study was featured in Academic Emergency Medicine as one of their CME articles – theoretically, an article with additional value presented with incentives to motivate a closer reading of the content. I don’t mean to imply this is somehow a bad article – but it’s just interesting to step back out of the tunnel vision of statistics and boggle at the inadequacy of the current state of medicine.

This is a prospective study of patients evaluated for pulmonary embolism attempting to evaluate how many patients were “inappropriately” scanned. This definition of “inappropriate” scanning was determined by patients who were either PERC negative or had low-risk Wells’ score followed by a negative d-Dimer. Overall, of 152 patients, 11.8% were ultimately diagnosed with PE. However, the authors state that application of the PERC rule might have eliminated 9.2% of these scans while Wells’/d-Dimer would have obviated 13.8%.

While I certainly don’t discount the beneficial effect of even small reductions in the number of individuals evaluated for pulmonary embolism, these are still terrible numbers. 90% of CT scans for PE are negative? And using these decision instruments gets us to ~75% negative scans? This would be comically wasteful performance and innovative performance improvement in any other industry.

We pretty clearly need to do better.

“Overuse of Computed Tomography Pulmonary Angiography in the Evaluation of Patients with Suspected Pulmonary Embolism in the Emergency Department”
www.ncbi.nlm.nih.gov/m/pubmed/23167851/

tPA Is The Hand That Feeds

No biting!

There are still a few hold-outs on the 0 to 3 hour window, but most folks would agree that battle is lost – the best we can hope for is further clarifying the patients with the greatest likelihood of clinically significant benefit vs. those with the greatest level of potential harms.

But, greater than 3 hours is still a battlefield. This article in the January Annals uses the gloriously unbalanced ECASS III data for a cost-effectiveness analysis which, unsurprisingly, concludes in favor of tPA treatment. The problem is, of course, the assumption that ECASS III is infallible – a highly suspect position, considering the baseline differences between groups in ECASS III. Then, accounting for the the 1200 patients in IST-3 enrolled in the 3 to 4.5 window who did poorly with tPA, I’m guessing an updated meta-analysis wouldn’t look quite as favorable. But, I will give these authors a bit of a break, as this article was accepted for publication before IST-3 results were available.

Finally, in lieu of my usual rant, I’ll just copy and paste the disclosures portion of the article:

“This project was funded through a contract with Genentech, Inc. Drs. Boudreau and Veenstra and Mr. Guzauskas served as a consultant for Genentech, Inc. Ms. Villa is employed by Genentech, Inc. Dr. Fagan is a consultant for Genentech, Inc.”

“A Model of Cost-effectiveness of Tissue Plasminogen Activator in Patient Subgroups 3 to 4.5 Hours After Onset of Acute Ischemic Stroke”