Archive for October 6th, 2008

It was only a matter of time…

by Paul Rega, MD — published on October 6th, 2008

NY Times, 10/5/08 (http://www.nytimes.com/2008/10/05/opinion/05sun3.html?_r=1&oref=slogin&ref=todayspaper&pagewanted=print): 

It is good to know that hospitals will no longer profit from their mistakes under a new payment policy just inaugurated by Medicare. Too bad the same will not be true of doctors, at least not yet.

Starting this month, Medicare will no longer pay hospitals for the added cost of treating patients who acquire any of 10 “reasonably preventable” conditions while hospitalized. Those include incompatible blood transfusions, severe bedsores, injuries from falls, poor blood sugar control, and infections after certain surgeries. The institution cannot bill the patient for these either. It must absorb the cost of repairing the damage it caused.

This is a small but hugely important step in the direction of paying hospitals based on the quality of care they deliver. It will not save much money at first — only about $21 million a year. In the long run, as the list of conditions is expanded and more insurers follow Medicare’s lead, the savings could be substantial.

The most important benefit will come if the new rules persuade hospitals to work harder to prevent errors and protect their patients.

The policy focuses exclusively on hospitals, as directed by Congress, and lets doctors off scot-free. If surgeons leave a sponge or an instrument in a patient and have to operate again to retrieve it, the hospital will not be paid for the second operation, but the surgeons will.

A new Medicare proposal would begin to address that inequity by denying payment to surgeons who operate on the wrong body part or the wrong patient. In theory, Medicare is not supposed to pay for such mistakes right now, as they are never reasonable and medically necessary. But Medicare is wisely seeking a national policy to ensure uniform payment decisions. That is a small but welcome step toward stopping doctors, not just hospitals, from making money off their errors.

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categories: Emergency Medicine

Binge Drinkers & Strokes

by Paul Rega, MD — published on October 6th, 2008

TITLE:  Increased Stroke Risk Is Related to a Binge Drinking Habit 

Source:  Stroke. 2008
Published online before print October 2, 2008, doi: 10.1161/STROKEAHA.108.520817

ABSTRACT

Background and Purpose—Heavy alcohol consumption increases the risk for all strokes, whereas moderate regular alcohol consumption is associated with a lower risk for ischemic stroke. The purpose of this study was to evaluate the effect of different drinking patterns on stroke risk, independent of average alcohol intake.

Methods—A prospective cohort study of 15 965 Finnish men and women age 25 to 64 years who participated in a national risk factor survey and had no history of stroke at baseline were followed up for a 10-year period. The first stroke event during follow-up served as the outcome of interest (N=249 strokes). A binge drinking pattern was defined as consuming 6 or more drinks of the same alcoholic beverage in men or 4 or more drinks in women in 1 session. Cox proportional-hazards models were adjusted for average alcohol consumption, age, sex, hypertension, smoking, diabetes, body mass index, educational status, study area, study year, and history of myocardial infarction.

Results—Binge drinking was an independent risk factor for total and ischemic strokes. Compared with non–binge drinkers, the hazard ratio for total strokes among binge drinkers was 1.85 (95% CI, 1.35 to 2.54) after adjusting for average alcohol consumption, age, and sex; the association was diluted after adjustment for other risk factors. Compared with non–binge drinkers, the risk for ischemic stroke was 1.99 (95% CI, 1.39 to 2.87) among binge drinkers; the association remained statistically significant after adjustment for potential confounders.

Conclusions—This study found that a pattern of binge drinking is an independent risk factor for all strokes and ischemic stroke.

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categories: Emergency Medicine

Developing resistance

by Paul Rega, MD — published on October 6th, 2008

BBC reported that “a study published in the journal Microbiology found bugs that survive disinfectant contact can become harder to kill.” Investigators “exposed Staphylococcus aureus bacteria to low concentrations of a wide range of antiseptic and antibacterial solutions, many of which are in common use in hospitals and the home.”

         1 Mr. & Mrs. Staph aureus

The researchers found “that because the bacteria were not killed by the chemicals, they began to mutate into new strains.” The investigators found that “these strains frequently had a higher number of ‘efflux pumps’, a feature found on the surface of their cells which allows them to get rid of toxic molecules.” The study leader “said that if bacteria in hospitals were exposed to ‘biocides’ — antibacterial chemicals — repeatedly, they could build up this resistance, and even contribute to hospital-acquired infections.”

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categories: Emergency Medicine

Victims of rape and sexual assault

by Paul Rega, MD — published on October 6th, 2008

In the LA Times (10/6, Ulene) M.D. column, Valerie Ulene, a board-certified specialist in preventive medicine wrote that many victims of rape and sexual assault “don’t get the medical care that they urgently need,” according to a study published in the journal Contraception.

In the study, “researchers at the John H. Stroger Jr. Hospital of Cook County in Chicago identified 10 services they said should be offered to victims, usually women, after a sexual assault, such as rape crisis counseling and preventive treatment of sexually transmitted diseases.”

Then, the researchers “queried 187 emergency departments across Illinois (156 of which responded) and found that fewer than one in 10 routinely provided all of the services.” While “all of the emergency [departments] provided medical care to assault victims,” only “two-thirds offered rape crisis counseling and only 40 percent made emergency contraception available to their patients.” Meanwhile, approximately “two-thirds reported that they tested and treated for sexually transmitted infections, and less than one-third provided precautionary HIV treatment.” The Times notes that “other studies have shown similar results.”

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categories: Emergency Medicine

Exercise-Induced Ventricular Arrhythmia

by Paul Rega, MD — published on October 6th, 2008

Association of Electrocardiographic Morphology of Exercise-Induced
Ventricular Arrhythmia with Mortality
Robert E. Eckart, Michael E. Field, Tomasz W. Hruczkowski, Daniel E.
Forman, Sharmila Dorbala, Marcelo F. Di Carli, Christine E. Albert, William
H. Maisel, Laurence M. Epstein, and William G. Stevenson
Ann Intern Med 2008;149 451-460
ABSTRACT

Background: The prognostic importance of exercise-induced ventricular arrhythmia (EIVA) may be confounded by the presence of lower-risk idiopathic right ventricular outflow tract arrhythmias with left bundle-branch block (LBBB) morphology. Objective: To determine whether right bundle-branch block (RBBB)–morphology EIVA was associated with increased mortality.

Design: Retrospective cohort.

Setting: Academic medical center.

Patients: 585 unique patients with EIVA and 2340 patients without EIVA, matched by age, sex, and risk factor, who were referred for exercise testing in an academic medical center.

Measurements: Deaths and ischemia and infarction found on perfusion scan.

Results: During a mean follow-up of 24 months (SD, 13), 31 deaths occurred in the EIVA group compared with 43 deaths in the group without EIVA (5.3% vs. 1.8%; P < 0.001). Worse survival in patients with RBBB-morphology or multiple-morphology EIVA (6.9%) than in patients without EIVA caused this difference. Patients with LBBB-morphology EIVAs had a mortality rate (2.5%) similar to that of patients without EIVA (P = 0.93, log-rank test). Among patients without known atherosclerotic coronary artery disease, any RBBB-morphology EIVA was associated with death (hazard ratio, 2.73 [95% CI, 1.78 to 4.13]; P < 0.001), but LBBB-morphology EIVA was not (hazard ratio, 0.82 [CI, 0.18 to 2.04]; P = 0.72).

Limitations: Not all LBBB-morphology EIVA can be dismissed, and not all RBBB-morphology EIVA is high risk. Further evaluation of patients for structural heart disease was clinically driven, not protocol-driven.

Conclusion: Right bundle-branch block– or multiple-morphology EIVA is associated with increased mortality. Inclusion of patients with isolated LBBB-morphology EIVA, which often is idiopathic, may contribute to differences in the prognostic importance of EIVA in previous studies.

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categories: Emergency Medicine

OMNI Postings of 10/6/08

by Paul Rega, MD — published on October 6th, 2008
On this date in 1889, Thomas Edison showed his 1st motion picture.  I won’t tell you the subject matter, but by the next day, all the raincoats in the local department store were sold out.

But I digress…
1)  Over the weekend, I posted new material about Lyme Disease from MMWR.  I thought you might like to see examples of its major dermal manifestation:  erythema migrans.
2)  The USDA is warning the public to cook their frozen chicken dinners thoroughly.  According to a rather vague report from ProMEDmail, an ID website, people across 12 states have contracted salmonellosis after eating these culinary delights.  The report does not specify what states or what brand of frozen chicken dinners are involved.
3) This is a NEJM study on tiotropium or aka, Spiriva.  This study conducted over 4 years showed that therapy with Spiriva was associated with improvements in lung function, quality of life, and exacerbations.
4)  What do you think this rash is on this infant?  If you said _______ then you are correct.   Then I’m sure you know what the usual time-honored remedies are.  But do you know what the therapy is for an infant under 2 months of age or for a pregnant woman? 
5)  For the young whipper-snappers amongst us, the use of US in the ER by ER docs is as common as an Alaskan governor saying, “You betcha.”  Here is a case report of an unusual condition where the US made the diagnosis.  BTW, I bet they cleaned that probe extra special good.
Welcome to all you guys & gals,
Paul R.
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categories: Emergency Medicine

Beware frozen chicken dinners!

by Paul Rega, MD — published on October 6th, 2008

ProMEDmail, 10/5/08

The USA government is urging consumers to thoroughly cook frozen
chicken dinners after 32 people in 12 states were sickened with
salmonellosis. The health warning by the USA Department of
Agriculture (USDA) cited frozen dishes in which the chicken is raw,
but breaded or pre-browned, giving the appearance of being cooked.
They include “chicken cordon bleu,” “chicken Kiev,” or chicken
breasts stuffed with cheese, vegetables, or other items.

USDA said many of the people who became ill apparently did not follow
the package’s cooking instructions and microwaved the chicken dishes
even though the instructions did not provide for it. Microwaving
didn’t heat the meals enough to kill the bacteria. The department
said consumers should cook chicken products to a minimum internal
temperature of 165 deg F (74 deg C).

USDA’s Food Safety and Inspection Service (FSIS) issued the warning
Friday [3 Oct 2008] after Minnesota health officials found a link
between the chicken dinners with salmonella illnesses reported in
Minnesota and 11 other states. It did not name the states in its
release, and did not immediately respond to a message left at its
press office seeking that information.

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categories: Emergency Medicine

You never know…

by Paul Rega, MD — published on October 6th, 2008

Intro:  What the heck was this woman thinking?  Good Vice-Presidential material there.  You betcha!

ProMEDmail, 10/3/08:  A parent brought a dead bat to Stevensville Elementary School earlier 
this week, and school officials are encouraging any child who touched 
the bat to get a series of rabies shots.

                      1

Stevensville Superintendent Kent Kultgen said the woman brought the
dead bat to school Monday [29 Sep 2008] morning and showed it to the
kindergarten and 5th-grade classmates of her children. She talked
about the bat and allowed students to touch the dead animal and gave
them hand sanitizer to wash their hands.

When school officials were notified, they called county and state
health officials, sent letters home with every student who may have
been exposed and sent the bat to a laboratory for testing. The bat
had rabies.

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categories: Emergency Medicine

Cardiac Troponin I (TnI)

by Paul Rega, MD — published on October 6th, 2008

Enhancing the diagnostic performance of troponins in the acute care setting
Salman A. Haq, Morteza Tavakol, Steven Silber, Larry Bernstein, Jerard Kneifati-Hayek, Madeleine Schleffer, Lesan T. Banko, John F. Heitner, Terrence J. Sacchi, Joseph A. Puma
The Journal of Emergency Medicine – 29 September 2008 (10.1016/j.jemermed.2008.02.049)

ABSTRACT

Background: Current guidelines define cardiac troponin I (TnI) as an indicator of necrosis when the concentration exceeds the 99% upper limit of a healthy reference population, a reference value near the assay’s lowest detectable level. We assessed the utility of a modified TnI cutoff point derived from a population at low risk for coronary artery disease (CAD) and evaluated its utility in determining acute myocardial infarction (MI).

Methods: A modified TnI cutoff point was derived by the receiver operating characteristic (ROC) curve from 737 consecutive patients who underwent serial TnI measurements for exclusion of MI. Creatinine kinase isoenzyme MB (CK-MB) evolutionary change was used to define MI. The new derived cutoff point was validated using another subset of 320 patients who were evaluated for MI.

Results: ROC-derived TnI cutoff point (A) was 0.65 μg/L, and its performance was compared to the recommended cutoff point ([B] 0.15 μg/L). Cutoff point A had greater specificity (94.5% vs. 86.9%, p < 0.001) but slightly lower sensitivity (96.5% vs. 100%, p < 0.01). Cutoff point A provided significantly greater positive predictive value (PPV) for MI (74.1% vs. 55.5%, p < 0.0001) and fewer false-positive errors, while preserving comparable negative predictive value (NPV) (98.9% vs. 100%).

Conclusion: A higher cutoff point derived from a reference population of patients at low risk for CAD may improve the TnI performance assay. The PPV for diagnosis of MI was significantly higher and false-positive values were fewer without affecting the NPV. The more reliable diagnosis of MI may have resulted, which, in turn, may have significant clinical and economic implications.

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categories: Emergency Medicine

ER Medication Errors

by Paul Rega, MD — published on October 6th, 2008

National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors
Julius Cuong Pham, Julie L. Story, Rodney W. Hicks, Andrew D. Shore, Laura L. Morlock, Dickson S. Cheung, Gabor D. Kelen, Peter J. Pronovost
The Journal of Emergency Medicine – 29 September 2008 (10.1016/j.jemermed.2008.02.059)
 ABSTRACT

Background: Medication errors contribute to significant morbidity, mortality, and costs to the health system. Little is known about the characteristics of Emergency Department (ED) medication errors.

Study Objective: To examine the frequency, types, causes, and consequences of voluntarily reported ED medication errors in the United States.

Methods: A cross-sectional study of all ED errors reported to the MEDMARX system between 2000 and 2004. MEDMARX is an anonymous, confidential, de-identified, Internet-accessible medication error-reporting program designed to allow hospitals to report, track, and share error data in a standardized format.

Results: There were 13,932 medication errors from 496 EDs analyzed. The error rate was 78 reports per 100,000 visits. Physicians were responsible for 24% of errors, nurses for 54%. Errors most commonly occurred in the administration phase (36%). The most common type of error was improper dose/quantity (18%). Leading causes were not following procedure/protocol (17%), and poor communication (11%), whereas contributing factors were distractions (7.5%), emergency situations (4.1%), and workload increase (3.4%). Computerized provider order entry caused 2.5% of errors. Harm resulted in 3% of errors. Actions taken as a result of the error included informing the staff member who committed the error (26%), enhancing communication (26%), and providing additional training (12%). Patients or family members were notified about medication errors 2.7% of the time.

Conclusion: ED medication errors may be a result of the acute, crowded, and fast-paced nature of care. Further research is needed to identify interventions to reduce these risks and evaluate the effectiveness of these interventions.

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categories: Emergency Medicine

Cocaine & Hyperthermia

by Paul Rega, MD — published on October 6th, 2008

Cocaine-induced agitated delirium with associated hyperthermia: A case report
Jay Menaker, David A. Farcy, Sharon A. Boswell, Deborah M. Stein, Richard P. Dutton, John R. Hess, Thomas M. Scalea
The Journal of Emergency Medicine – 29 September 2008 (10.1016/j.jemermed.2008.02.055)

ABSTRACT

Background: “Cocaine-induced agitated delirium with associated hyperthermia” is a rare, almost uniformly fatal syndrome. The incidence of the disease is not known, however, it is believed to have markedly increased since the late 1980s with widespread popularity of crack cocaine.

Objective: Recent literature is lacking regarding this rare syndrome. Although almost uniformly fatal, we present a neurologically intact survivor due to a multidisciplinary team approach.

Case Report: We are reporting a 41-year-old African-American man who arrived at the trauma center with a rectal temperature of 42.6°C (108.6°F) and a toxicology screen positive for cocaine. The patient manifested many of the known complications of cocaine-induced agitated delirium with associated hyperthermia, including renal failure and coagulation panel abnormalities. With early application of cooling techniques, including ice pack, gastric lavage, and bilateral chest cavity lavage using multiple chest tubes, the patient’s core temperature was quickly lowered.

Conclusion: This case demonstrated how a multidisciplinary team approach, including emergency medicine and critical care specialists, and aggressive treatment of hyperthermia using bilateral tube thoracostomy and chest cavity lavage enabled our patient’s core temperature to be effectively lowered. We were unable to find prior reports of using tube thoracostomy in this manner.

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categories: Emergency Medicine

Atrial Fibrillation Formula

by Paul Rega, MD — published on October 6th, 2008

A formula for the stratified selection of patients with paroxysmal atrial fibrillation in the emergency setting: A retrospective pilot study
Despina N. Perrea, Konstantinos A. Ekmektzoglou, Ioannis S. Vlachos, Serafim Tsitsilonis, Eleni Koudouna, Konstantinos Stroumpoulis, Theodoros Xanthos
The Journal of Emergency Medicine – 02 October 2008 (10.1016/j.jemermed.2008.02.062)

Background: Amiodarone is a commonly used medication in the treatment of atrial fibrillation (AF) of recent onset.

Study Objectives: The aim of the study was to identify a possible formula for selecting Emergency Department (ED) patients with paroxysmal AF who will spontaneously restore sinus rhythm (SR), successfully restore SR with the use of loading intravenous (i.v.) amiodarone, or require 24-h maintenance amiodarone infusion.

Methods: This retrospective pilot study included 141 patients with recent-onset AF. Patients who did not restore SR spontaneously received i.v. amiodarone (5 mg/kg) within a period of 30 min. In case of no response, an additional dosage of 1000 mg of i.v. amiodarone was administered over a period of 24 h. Binary logistic regression models were used to determine the predictors of spontaneous conversion and the response to amiodarone administration.

Results: The formula ([heart rate/systolic blood pressure] + 0.1 × number of past AF incidences) was chosen as the one with the highest combined sensitivity and specificity. This index identified the patients who spontaneously restored SR (cutoff point 1.31 with 78.6% sensitivity and 77.9% specificity), whereas for patients who responded to the loading i.v. amiodarone dose, the use of the index (cutoff point 1.24) exhibited 84.1% sensitivity and 75.3% specificity.

Conclusions: This formula may be a useful and reliable bedside diagnostic tool to identify AF patients most likely to spontaneously convert, or respond to loading amiodarone administration in the emergency setting. The use of this index also can assist in patient risk stratification.

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categories: Emergency Medicine

A protocol for the treatment of acute hyperglycemia in the ED

by Paul Rega, MD — published on October 6th, 2008

Impact of a Subcutaneous Insulin Protocol in the Emergency Department: Rush Emergency Department Hyperglycemia Intervention (REDHI)
Christina Munoz, Grace Villanueva, Louis Fogg, Tricia Johnson, Katherine Hannold, Janyce Agruss, David Baldwin
The Journal of Emergency Medicine – 02 October 2008 (10.1016/j.jemermed.2008.03.017)

ABSTRACT

Objective: We evaluated a hyperglycemia treatment protocol for use in the Emergency Department (ED) in patients with diabetes mellitus (DM) before admission to the hospital or discharge home.

Methods: Fifty-four consecutive patients with a history of DM and an ED admission blood glucose (BG) > 200 mg/dL were treated with subcutaneous (SQ) insulin aspart every 2 h until BG was < 200 mg/dL. Point-of-care BG was measured immediately on ED admission and every 2 h until discharge home or hospital admission. The intervention group was compared with 54 historical controls with DM and an ED admission BG > 200 mg/dL.

Results: One hundred percent of intervention patients received insulin aspart, whereas only 35% of historical controls received insulin therapy. In the intervention group, mean BG declined from 333 ± 104 mg/dL on ED admission to 158 ± 68 mg/dL on ED discharge. In the historical control group, mean BG decline was significantly less, from 322 ± 126 mg/dL on admission to 242 ± 79 mg/dL on discharge (p < 0.001). Sixty-nine percent of intervention patients and 67% of controls were subsequently admitted to the hospital. Mean hospital length of stay (LOS) in the intervention group was significantly less, 3.8 ± 3.3 days, compared with 5.3 ± 4.1 days in the control group (p < 0.05). Four intervention patients (7.4%) developed a BG < 70 mg/dL.

Conclusion: A protocol for the treatment of acute hyperglycemia in the ED can be safely implemented. Subsequent inpatient LOS was reduced. Further randomized clinical trials of this intervention are warranted.

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categories: Emergency Medicine

Alexandrou Angle of Intubation

by Paul Rega, MD — published on October 6th, 2008

An innovative approach to orotracheal intubations: The position of Alexandrou Angle Of Intubation
Nikolaos A. Alexandrou, Benson Yeh, Paul Barbara, Mark Leber, Lewis W. Marshall
The Journal of Emergency Medicine – 02 October 2008 (10.1016/j.jemermed.2008.01.026)

ABSTRACT

Visualization of the vocal cords is paramount during orotracheal intubations. We employed a novel patient position in this derivation study. The Alexandrou Angle of Intubation (AAI) position is defined as a 20°–30° incline where the supine patient’s head is elevated in relation to the body and legs. Our study participants were blinded to the goals of the research as well as our novel technique. Using intubation manikins, our participants ranked their preference for visualizing the vocal cords between the Flat, Trendelenburg, and AAI positions. A majority (58.8%) of our study participants preferred the AAI for visualizing the vocal cords over the other two positions. Future studies will reveal whether AAI will play a significant role in emergent airway management.

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categories: Emergency Medicine

The Accuracy of Patients’ Med Lists

by Paul Rega, MD — published on October 6th, 2008

Emergency Department Medication Lists Are Not Accurate
Selin Caglar, Philip L. Henneman, Fidela S. Blank, Howard A. Smithline, Elizabeth A. Henneman
The Journal of Emergency Medicine – 02 October 2008 (10.1016/j.jemermed.2008.02.060)

ABSTRACT

Background: Medication errors are a common source of adverse events. Errors in the home medication list may impact care in the Emergency Department (ED), the hospital, and the home. Medication reconciliation, a Joint Commission requirement, begins with an accurate home medication list.

Objective: To evaluate the accuracy of the ED home medication list.

Methods: Prospective, observational study of patients aged > 64 years admitted to the hospital. After obtaining informed consent, a home medication list was compiled by research staff after consultation with the patient, their family and, when appropriate, their pharmacy and primary care doctor. This home medication list was not available to ED staff and was not placed in the ED chart. ED records were then reviewed by a physician, blinded to the research-generated home medication list, using a standardized data sheet to record the ED list of medications. The research-generated home medication list was compared to the standard medication list and the number of omissions, duplications, and dosing errors was determined.

Results: There were 98 patients enrolled in the study; 56% (55/98, 95% confidence interval [CI] 46–66%) of the medication lists for these patients had an omission and 80% (78/98, 95% CI 70–87%) had a dosing or frequency error; 87% of ED medication lists had at least one error (85/98, 95% CI 78–93%).

Conclusion: Our findings now add the ED to the list of other areas within health care with inaccurate medication lists. Strategies are needed that support ED providers in obtaining and communicating accurate and complete medication histories.


 

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categories: Emergency Medicine