Category: Triage

Pediatric Septic Shock Protocol

Another sort of goal-directed sepsis study, this time in Pediatrics at Primary Children’s.  They implemented a protocolized triage system in their ED designed explicitly identify more cases of sepsis – which led to increased percentages getting early fluid resuscitation, early lactate level measurements, and more frequently antibiotics in the first three hours.

But the net effect of all these interventions…the only detectable difference in their 345 patient cohort was improved length-of-stay for survivors, from IQR 103-328 hours pre-intervention to IQR 86-214 post-intervention.  Total hospital costs were not significantly different.  No change in mortality – which was already low at 7%.
So, yet again – adherence to “quality measures” has debatable clinical significance.

Massachusetts Health Reform Is “Working”

By some measures, at least, you can claim that the Health Reform is working.  I’ve seen a few articles out there saying it failed, because ED visits continue to rise.  But, if this study is reliable, the increases in ED utilization are a result in increased illness severity, not inability to access a physician.

Non-acute visits for the uninsured/low-income cohort in Massachusetts went down, from 43.8% to 41.2% – a greater decrease as compared to their “control” group of private insurance that is supposedly unaffected by health reform, which decreased from 35.7% to 34.9%.  So, one way to interpret this is that increased access has kept some of the non-urgent uninsured out of the ED.

…but they’re still seeing, by their definition, a solid nearly 40% of patients in our EDs that have less than a 25% of requiring true Emergency Department care.  So things have incrementally improved – but the problem is not simply that a patient has nominal access to a PMD, they actually need to be able to access that PMD on a semi-urgent basis to truly reduce ED utilization…and that PMD needs to be more than simply a revolving door back to the ED.

http://www.ncbi.nlm.nih.gov/pubmed/21570157

Vital Sign “Triggers”

So, this was an interesting article about a system of vital sign “triggers” an ED implemented to get nurses to flag specific patients for more urgent attention.  Not unexpectedly, the study finds that, when nurses get physician’s attention, everything happens more rapidly to those patients, orders, antibiotics, and disposition.  The problem is, the article doesn’t address the appropriateness or any unintended consequences of this sort of intervention.  The theory would be that these abnormal vital signs represent patients that need more urgent evaluation, but vital signs are always just one piece of the puzzle.  In any event, this study spotlights something that can be reasonably construed as important – nurses should be educated to recognize potentially ill patients and notify physicians.

Of course, in the back of my mind, I was envisioning our ED (and likely many around it) which rooms patients first, and then triages them – and it then becomes the responsibility of the nurse whose zone they have entered to take and record vital signs.  This results in patients being roomed much faster – which many studies have shown is likely a good thing.  Unfortunately, when a patient is roomed to the high-acuity side based on chief complaint, the nurse to which they are assigned may be quite busy with their other high-acuity patients…and that patient may just sit in the room for some time without an assessment or vital signs.

Everything has potential unintended consequences.

http://www.ncbi.nlm.nih.gov/pubmed/21521399