Category: Quality

Your New Career in “Waiting Room Medicine”

A few years back, a facetious advertisement in the Canadian Journal of Emergency Medicine promoted the availability of fellowship positions in “Waiting Room Medicine”, a comedic take on the struggles of the specialty to manage increasing patient volume with limited resources. While there are certainly Emergency Departments with ample space and “white glove”-type service – see the for-profit expansion of free-standing EDs in states like Texas – there are also publicly-funded and other EDs that struggle with physical bed space for patients for a variety of reasons.

This study attempts to quantify the effect of an intervention utilized by many overburdened or otherwise saturated EDs – starting the initial evaluation in triage with either provider-directed or protocolized orders. At UCLA/Olive-View, all patients presenting to an already-full ED received an initial rapid evaluation by an attending physician or nurse practitioner. During their 10-month study period, non-pregnant adults with abdominal pain were randomized to either receiving initial evaluation orders following this evaluation, or to be returned to the waiting room to await full evaluation at a later time pending bed availability.

There were 1,691 enrolled and randomized, with approximately 10% excluded from analysis mostly because they left the ED before their evaluation was complete. Overall, the initiation of the work-up in triage saved patients approximately a half-hour, on average, of bedded time in the ED. This was reflected by a similar absolute decrease in overall ED length-of-stay. There were a couple other interesting tidbits unique to their execution:

  • The most profound difference associated with WR medicine was simply blood and urine testing. While imaging could be ordered up front, it was rarely done.
  • Some of the advantages related to the WR blood testing were minimized by ~13% of patients receiving further testing after being bedded in the ED.
  • Patients randomized to WR medicine received, on average, a greater number of diagnostics per patient, probably representing resource waste.

So – yes, this probably accurately reflects the impact of orders placed in triage: some wasted resources based on the initial, incomplete evaluation, with a trade-off of potential time savings. The extent to which your system might benefit from a similar set-up is probably related to your level of chronic bed scarcity.

“Initiating Diagnostic Studies on Patients With Abdominal Pain in the Waiting Room Decreases Time Spent in an Emergency Department Bed: A Randomized Controlled Trial”
http://www.annemergmed.com/article/S0196-0644(16)30360-2/abstract

The Downside of Antibiotic Stewardship

There are many advantages to curtailing antibiotic prescribing. Costs are reduced, fewer antibiotic-resistant bacteria are induced, and treatment-associated adverse events are eliminated.

This retrospective, population-based study, however, illuminates the potential drawbacks. Using electronic record review spanning 10 years of general practice encounters, these authors compared infectious complication rates between practices with low and high antibiotic prescribing rates. Spanning 45.5 million person-years of follow-up after office visits for respiratory tract infections, there is both reason for reassurance and reason for further concern.

On the “pro” side, cases of mastoiditis, empyema, bacterial meningitis, intracranial abscess and Lemierre’s syndrome were no different between those who prescribed high rates (>58%) and those with low rates (<44%). However, there is a reasonably clear linear relationship with excess follow-up encounters for both pneumonia and peritonsilar abscess. Incidence rate ratios were 0.70 compared with reference for pneumonia and 0.78 compared with reference for peritonsillar abscess. However, the absolute differences can best be described as “large handful” and “small handful” of extra cases per 100,000 encounters

There are many rough edges and flaws relating to these data, some of which are probably adequately defeated by the massive cohort size. I think it is reasonable to interpret this article as accurately reflecting true harms from antibiotic stewardship. More work should absolutely be pursued in terms of strategies to mitigate these potential downstream complications, but I believe the balance of benefits and harms still falls on the side of continued efforts in stewardship.

“Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records”

http://www.bmj.com/content/354/bmj.i3410

The “IV Antibiotics” Sham

Among the many overused tropes in medicine is the myth of the supremacy of intravenous antibiotics.  In the appropriate clinical context, it’s just a waste.

This is a retrospective analysis of 36,405 patients hospitalized for community-acquired pneumonia, and for whom a fluoroquinolone was selected as therapy.  The vast majority – 94% – received an intravenous dose, while the remaining 2,205 (6%) were treated orally.  Unadjusted mortality favored the oral dose – unsurprisingly, as those patients also generally has fewer comorbid conditions.  In their multivariate, propensity-matched analysis, there was no difference in mortality, intensive care unit escalation, or mechanical ventilation.

These results are wholly unsurprising, and the key feature is the class of antibiotic involved.  Commonly used antibiotics in the fluoroquinolone class, trimethoprim-sulfamethoxazole, metronidazole, and clindamycin, among others, have excellent oral absorption.  I have seen many a referral to the Emergency Department for “intravenous antibiotics” prior to an anticipated discharge to home therapy when any one of these choices could have obviated the entire encounter.

“Association Between Initial Route of Fluoroquinolone Administration and Outcomes in Patients Hospitalized for Community-acquired Pneumonia”
http://www.ncbi.nlm.nih.gov/pubmed/27048748

Pan-Scans Don’t Save Lives

Humans are fallible.  We don’t always make good choices, and our patients – bless their hearts – can sometimes be time bombs wrapped in meat.  Logically, then, as many trauma services have concluded, the solution is to eliminate the weak link: don’t let the human chose which parts of the body to scan – just scan it all.

This is REACT-2, a randomised [sic] trial evaluating precisely the limits to human judgment in a resource-utilization versus immediacy context.  In this multi-center trial, adult trauma patients wth suspected serious injury were randomized to either imaging guided by clinical evaluation or total-body CT.  The primary outcome was in-hospital mortality, with secondary outcomes relating to timeliness of diagnosis, to mortality in other time frames, morbidity, and costs.

This was a massive undertaking, with 1,403 patients randomly assigned to one of the arms, with ~540 in each arm successfully allocated and included in their primary analysis.  Each cohort was well-matched on baseline characteristics, including all physiologic markers, although the Triage Revised Trauma Score was slightly lower (worse) for the total-body CT group.  The results, in most concise form, weakly favor selective scanning.  There was no difference in mortality nor complications nor length-of-stay nor virtually any reliable secondary outcome.  Costs, as measured in European terms, were no different, despite the few scans obviated.  Time-to-diagnosis was slightly faster in the total-body CT group, owing to skipping initial conventional radiography, while radiation exposure was slightly lower in the selective scanning group.

In some respects, it is not surprising there were no differences found – as CT was still frequently utilized in the selective CT cohort, including nearly half that ultimately underwent total-body CT.  There were some differences noted in in-hospital Injury Severity Score between groups, and I agree with Rory Spiegel’s assertion this is probably an artifact of the routine total-body CT.  This study can be used to justify either strategy, however – with selective CT proponents focusing on the lack of differences in patient-oriented outcomes, and total-body CT proponents noting minimal resource and radiation savings at the expense of timeliness.

“Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial”
http://www.ncbi.nlm.nih.gov/pubmed/27371185

Excitement and Ennui in the ED

It goes without saying some patient encounters are more energizing and rewarding than others.  As a corollary, some chief complaints similarly suck the joy out of the shift even before beginning the patient encounter.

This entertaining study simply looks for any particular time differential relating to physician self-assignment on the electronic trackboard between presenting chief complaints.  The general gist of this study would be that time-to-assignment reflects a surrogate of a composite of prioritization and/or desirability.

These authors looked at 30,382 presentations unrelated to trauma activations, and there were clear winners and losers.  This figure of the shortest and longest 10 complaints is a fairly concise summary of findings:

door to eval times

Despite consistently longer self-assignment times for certain complaints, the absolute difference in minutes is still quite small.  Furthermore, there are always issues with relying on these time stamps, particularly for higher-acuity patients; the priority of “being at the patient’s bedside” always trumps such housekeeping measures.  I highly doubt ankle sprains and finger injuries are truly seen more quickly than overdoses and stroke symptoms.

Vaginal bleeding, on the other hand … is deservedly pulling up the rear.

“Cherry Picking Patients: Examining the Interval Between Patient Rooming and Resident Self-assignment”
http://www.ncbi.nlm.nih.gov/pubmed/26874338

Choosing Wisely – Invisible, Impractical

There are two parts to Choosing Wisely – the “Five Things” and then the bit where “Physicians and Patients Should Question” them.  Most specialities – for better or worse – have generated lists of five things.  Some go beautifully against the grain, like Pediatric Hospital Medicine.  Others are criticized for mostly what is lacking.

Regardless, these suggestions work only when physicians are aware of them, and their suggestions are practical.  This survey of outpatient physicians in a group in the state of Massachusetts, unfortunately, is rather bleak.  At best, 47.2% of primary care physicians were aware of Choosing Wisely, compared with a mere 27% of surgical specialists.  In a similar pattern, less than half and then less than a quarter of PCPs and surgeons felt Choosing Wisely was “Yes, absolutely” a legitimate source of guidance.  Finally, just over half of all physicians surveyed felt the Choosing Wisely campaign had empowered them to reduce testing and procedures.

This is, of course, better than zero – which was effectively the base case.  That said, these authors identified many barriers to their use.  Physicians preferred to serve their patients desires and interests over the guidelines and recommendations made based on medical evidence.  Further, most all physicians expressed a fear of malpractice and legal difficulties.

Awareness, certainly, would be a start.  Then, making these recommendations usable in practice – moreso than then currently are – might be the next step in helping physicians bring them into the conversation.

“Physician Perceptions of Choosing Wisely and Drivers of Overuse”
http://www.ajmc.com/journals/issue/2016/2016-vol22-n5/physician-perceptions-of-choosing-wisely-and-drivers-of-overuse

Severe Sepsis … or ß-Agonist

As our sepsis overlords entrenched new “quality measures” and other protocol-driven resuscitation requirements in our Emergency Departments, this article serves as a lovely reminder of the importance of staying cognitively engaged.

Lactate levels can be elevated by metabolic and microcirculatory derangements related to the spectrum of sepsis – but also other, non-infectious causes.  These include hepatic disease, multiple toxodromes, and multiple medications – one of the most commonly used being beta-agonist therapy for obstructive airways.  This very simple study examines the physiologic changes in healthy volunteers receiving 10mg of nebulized albuterol, as compared with nebulized saline.  Placebo volunteers had no change in lactate or placebo.  Albuterol receiving volunteers had an average increase in lactate of 0.77 mmol/L and an average decrease in potassium of 0.5 mEq/L.  Lactate increases, however, were highly variable – ranging from 0.04 to 2.02 mmol/L.

These data aren’t perfectly generalizable to the critically or pseudo-critically ill, but they’re a reasonable starting point for a gross estimate.  They’re also justification for reconsideration of potentially inappropriate therapies for an intermediate-range lactate that obstinately refuses to clear – in the context of receiving multiple rounds of nebulizers.

At the very least, it’s a reminder of the various exceptions to our protocols we need to consider to prevent costly and avoidable harms.

“The Effect of Nebulized Albuterol on Serum Lactate and Potassium in Healthy Subjects”
https://www.ncbi.nlm.nih.gov/pubmed/26857949

The Unmagical Checklist

The checklist has reached ascendant status in medicine.  As introduced into the mainstream by Atul Gawande, they have begun to permeate every nook of healthcare delivery.  However, evidence of benefit when applied to one particular problem in one particular setting is no guarantee of universal utility.

These authors performed a study in Brazilian intensive care units, using a cluster-randomized pre/post design to evaluate the effect of a quality improvement effort built around a checklist.  Each element on the checklist represented a consensus or evidence-based practice associated with improvement in surrogate markers for patient outcomes.  The combined intervention was hoped to improve overall in-hospital mortality for ICU patients at the intervention hospitals.

It didn’t – mortality increased similarly for both intervention and control ICUs.

In fact, for all secondary clinical outcomes – catheter-related infections, ventilator-associated pneumonia, urinary tract infections, ICU days, etc. – there were no significant improvements over the baseline period, and no difference compared with controls.  There were small improvements in processes of care, such as VTE prophylaxis, catheter use, and appropriate tidal volumes during ventilation – but without corresponding clinical outcome improvement.

Interestingly, clinicians working in the intervention ICUs typically felt as though their ICUs were safer.  They were more likely, sometimes significantly so, to provide answers reflecting positive associations regarding their working conditions and safety climate.  Indeed, the intervention was perceived as so likely to be beneficial even prior to the start of the study that a short duration was mandated for the trial so all ICUs could eventually start using the checklist.

These authors have several justifications for why their checklist did not function appropriately, focusing on various details regarding the trial.  I think the simplest expression regarding the effectiveness of a checklist relates to the magnitude of effect and the baseline frequency of adherence.  Unless a significant magnitude of effect is seen by improving compliance with an intervention, and the intervention itself is infrequently performed, returns will diminish dramatically.  A checklist such as this, with multiple low-yield elements, is unlikely to return substantial patient-oriented outcome improvements.  Indeed, the resources devoted to checklist rounding and adherence may even dilute the focus on important clinical considerations.

“Effect of a Quality Improvement Intervention With Daily Round Checklists, Goal Setting, and Clinician Prompting on Mortality of Critically Ill Patients”
https://www.ncbi.nlm.nih.gov/pubmed/25928627

Hospitalization or Home After TIA

In the pursuit of “value-based care”, innovators are consistently looking for ways to deliver similar outcomes without the risks and resource utilization of inpatient hospitalization.  One of these realms is the evaluation of transient ischemic attack.  Most of the recommended follow-up tests are only relatively urgent in nature, and with medical management the typical mainstay of therapy.  As serious considerations go, it seems ripe a candidate for outpatient management.

This retrospective look at outcomes from Canada, however, suggests there may be pitfalls to such a strategy.  These authors reviewed the outcomes of 8,540 patients presenting with TIA or minor stroke, and compared those either admitted to the hospital at the index visit with those discharged, and among those discharged, referral to a specialized follow-up clinic or not.

Patients admitted to the hospital, by all measures, had more severe cerebrovascular disease – as evidenced by duration of symptoms, ABCD2 scores, diagnosis of minor stroke, and other comorbidities.  However, despite this, following hospitalization, these patients had the lowest risk or recurrent stroke or TIA within one year.  The benefit, presumably, comes from increased likelihood of undergoing risk stratification and treatment – carotid imaging, echocardiography, appropriate anticoagulation, appropriate antithrombotic therapy, and the like.  Then, among the discharged, various adjusted and propensity matched analysis demonstrated a protective effect of referral to specialty outpatient follow-up against death, but not for stroke or TIA.  These data do not have the granularity to fully describe whether the excess deaths were in some fashion related to cerebrovascular disease.

Most of the absolute differences in outcomes between groups are small – a few percentage points each, and smaller after adjustment.  That said, it’s probably clearly superior care, as configured in Ontario during this time frame, to have been admitted to the hospital.  As TIA evaluation, and other similar conditions, move to outpatient pathways rather than traditional hospitalization, this represents an important reminder of potential risks of degradation in thoroughness and quality.

“Association between hospitalization and care after transient ischemic attack or minor stroke”
https://www.ncbi.nlm.nih.gov/pubmed/27016521

Get On Up

Patients who linger in the Emergency Department may seem harmless – but, in reality, even a few minutes of added occupancy reduces availability for services by that much, to the point where excessive boarding may greatly diminish the ability to care for additional patients.  In many settings, such as County facilities or other space-limited departments, throughput is critical to maximizing the effectiveness of the resource.

This is a single-center descriptive study of a process improvement effort regarding the use of ED holding orders.  Rather than wait for the admitting team to fully evaluate a patient and place admission orders, the ED providers were given the authority to admit patients using a set of basic bridging orders prior to full assessment.  Their story is a success story – which is not at all surprising because their baseline state was that of nearly 7-hour ED length-of-stay for admitted patients.  Of that 7 hour baseline, over 3 hours was time elapsed between the ED physician making a decision to admit and the patient departing the ED.  After implementation of these holding orders, the ~200 minute ED loitering period was reduced to ~90 minutes – which, frankly, is still quite excessive.

It probably ought surprise no one giving the power to move patients to those most motivated to move them dramatically improves the alacrity of their departure.  These authors, however, appropriately note very little of the downstream effects were measured.  Their determination of attributable harms is reported as “purely anecdotal”, and only one instance of potential harm – a patient without the proper glucose monitoring orders on the floor – was observed.  This is probably not an entirely adequate assessment of this process change intervention, although I tend to agree true harms are likely to be vanishingly rare.

Simply put – there’s not much downside, and, in our increasingly space-strapped EDs, there’s a great deal of upside.  Clearly, unless your institution is as inefficient at baseline as the one featured in this article, the improvements will not be as profound.  But, for many hospital systems, these sorts of orders have been routine for quite some time – and it’s one more reasonable venue to intervene to improve ED LOS.

“Sustainable Mechanism to Reduce ED Length of Stay: The Use of Emergency Department Holding (ED Transition) Orders to Reduce ED Length of Stay.”
https://www.ncbi.nlm.nih.gov/pubmed/26999707