ED Push - December 2015 First Issue
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Therapeutic Hypothermia Increases Survival in ‘Non-Shockable’ Heart Patients
AURORA, CO – Survival rates and brain function are increased when body temperature is lowered for cardiac arrest patients – even if they have “non-shockable” heart rhythms.
That’s according to a new study, published recently in the journal Circulation. While previous studies have indicated that therapeutic hypothermia (TH) can improve survival and neurological function, it usually is recommended only for patients with "shockable" rhythms such as ventricular fibrillation.
A study team lead by University of Colorado School of Medicine researchers suggests that therapeutic hypothermia might also benefit comatose cardiac arrest patients with "non-shockable" heart rhythms who don’t respond to defibrillation because of a lack of pulse or electrical activity in the heart.
For the study, researchers examined data from 519 patients who had a cardiac arrest due to a non-shockable heart rhythm in the Penn Alliance for Therapeutic Hypothermia (PATH) registry between 2000 and 2013.
Those who received therapeutic hypothermia were 2.8 times more likely to survive after cardiac arrest and 3.5 times more likely to have better neurologic recovery compared to those who were not cooled, according to the results.
"Neurologic injury after cardiac arrest is devastating," said lead author Sarah Perman, MD, of the University of Colorado. "We have one chance to give some form of neuroprotection, and that's immediately after the arrest.
"Our resources right now are not extensive and our outcomes are still fairly grim,” she added. “Therapeutic hypothermia is one therapy we do have in our arsenal, and if a patient is comatose after arrest, it's very important to consider applying this therapy, specifically in patients who are neurologically injured.”
Background information in the study points out that, despite established guidelines for the use of therapeutic hypothermia in patients who suffer cardiac arrest, use is low, especially for in-hospital cardiac arrest patients and those who arrest with initial non-shockable rhythms.
"The perception that there is no benefit to patients who have an initial non-shockable rhythm has hindered application," Perman said.
“Using propensity score matching, we found patients with non-shockable initial rhythms treated with TH had better survival and neurologic outcome at hospital discharge than those who did not receive TH,” study authors conclude. “Our findings further support the use of TH in patients with initial non-shockable arrest rhythms.”
EHR Alerts on Opioids: Too Much of a Good Thing?
DENVER – Perhaps based on the theory that, if a little is good, a lot must be better, emergency medicine professionals are being overwhelmed with electronic health record alerts on opioids.
That’s according to a study, published online recently by Annals of Emergency Medicine, which offered this example: To prevent a single adverse drug event, one commercial electronic health record opioid warning system broadcast 123 unnecessary and clinically inconsequential alerts.
"The danger here is that medical providers may develop 'alert fatigue,' leading to compromised patient safety,” said lead study author Emma Genco, MS, of the University of Colorado School of Medicine in Denver. “It is well established that clinical decision support prevents adverse drug events, but it is essential that alerting systems be refined to highlight only the clinically significant alerts."
The retrospective chart review study focused on type, override rates, events and event preventability with opioid drug alerts to assess adverse drug event occurrences for ED visits in a large urban academic medical center using a commercial EHR system with clinical decision support. Participants were adults who arrived to the ED every fifth day between September 2012 and January 2013.
The study points out that, while 14 of 4,581 patients experienced an adverse drug event (ADE), with eight due to opioids, none turned out to be preventable by the clinical decision support alert of the commercial EHR.
In fact, 98.9% percent of opioid alerts did not result in an actual or averted ADE and 96.3% of opioid alerts were overridden, according to the results.
Opioid drug alerts were more likely to be overridden than non-opioid alerts. In addition, opioid drug allergy alerts were twice as likely to be overridden, while opioid duplicate therapy alerts were 1.57 times as likely to be overridden.
Most likely to override the alerts were pharmacists and physicians assistants; medical residents were the least likely to override.
“Overridden opioid alerts did not result in adverse drug events,” study authors conclude. “Clinical decision support successfully prevented adverse drug events at the expense of generating a large volume of inconsequential alerts.”
"We need to improve the 'signal to noise' ratio of these alerts, especially in the chaotic environment of the emergency department," Genco said. "Interruptions are already a significant fact of life in emergency departments, which is why we need to eliminate the meaningless ones."
Older Dementia Patients More Likely to Visit EDs, Incur Greater Costs
INDIANAPOLIS – The information won’t be much of a surprise to emergency physicians, but older adults with dementia are more frequent visitors to emergency departments, returning at higher rates and incurring greater costs than older adults without dementia.
The study, published recently in the journal Alzheimer's Disease and Associated Disorders, is one of the first to explore long-term patterns of healthcare use and mortality rates of elders with cognitive impairment who visit the ED.
Researchers from the Regenstrief Institute and the Indiana University Center for Aging Research also found that older adults with dementia are more likely to be admitted to the hospital and are more likely to die following an ED visit than those without dementia.
The study focused on 32,697 patients 65 and older – with and without dementia – who sought emergency care over an 11-year period at Eskenazi Health, a large, urban, safety-net healthcare system.
In any given year, between one-third and one-half of older adults visited the ED. Five years after their first emergency department visit, only 46% of those with dementia were alive compared to 76% those without dementia.
"As people live longer we will increasingly be faced with a growing number of individuals with cognitive impairment. We now know that survival rates after an ED visit differ significantly by cognitive status," said lead author Michael LaMantia, MD, MPH. "We need to continue to learn how to provide better care to these vulnerable individuals in fast-paced emergency departments and after their visits to the ED.
"Our findings, which were controlled for age, race, gender and health conditions in addition to degree of cognitive impairment, fill in gaps in knowledge about trajectories of care for older adults with dementia and provide an evidence-based starting point for future investigations that we should not defer,” LaMantia added.
Among other findings is that 53% of patients with dementia visiting the ED were discharged rather than being admitted to the hospital. Study authors say that raises the question of the medical necessity of the ED visit and whether care could have been provided in a lower cost setting. On the other hand, they ask, were decisions to discharge flawed, due to missed medical complications, incomplete assessments of the safety of the patient's home environment or other factors?
"Emergency departments are appropriately focused on recognizing and stabilizing acute life-threatening conditions and should not be, but are often used as, a substitute for ongoing comprehensive primary care especially for those, like patients with dementia, whose evaluations and management require more intensive, time-consuming, and multidisciplinary resources," added co-author Frank Messina, MD.
Text Helps Young Adults Autocorrect Their Binge Drinking Issues
PITTSBURGH – With all of the buzz about providing interventions in the emergency department to combat excessive drinking, researchers at the University of Pittsburgh appear to have found an alternative way to do that.
Results of a trial to test a text message-based program aimed at reducing binge drinking was published online recently by PLOS ONE. It is the first to show that such an intervention can successfully produce sustained reductions in alcohol consumption in young adults.
The program was designed by lead author Brian Suffoletto, MD, an emergency physician at Pitt. A study showed that it reduced binge drinking and alcohol-related injuries when compared to a control group and a self-monitoring group, with the positive effect continuing six months after program end.
"Given the low cost to send text messages and the capacity to deliver them to almost every at-risk young adult, a text message-based intervention targeting binge drinking could have a public health impact on reducing both immediate and long-term health problems," Suffoletto said in a University of Pittsburgh Schools of the Health Sciences press release.
For the 12-week trial, 765 18- to 25-year-olds who were discharged from four urban emergency departments in western Pennsylvania were randomized into three groups: The control group received standard care and no text messages; the self-monitoring group received text messages on Sundays asking about drinking quantity but received no feedback; the final group received the full program, which consisted of text messages on Thursdays inquiring about weekend drinking plans and promoting a commitment to limit drinking, followed by another text on Sunday to inquire about actual drinking and give tailored feedback aimed at reducing alcohol consumption.
If participants in the full intervention program reported they were facing a heavy drinking day where they were likely to have more than five drinks during any 24-hour period for men and more than four for women, they received a text message expressing concern about those levels and asking if they would set a goal to limit their drinking below binge thresholds for the weekend.
Participants who agreed to do that received messages with positive reinforcement as well as strategies for cutting down on drinking. On the other hand, those who refused to set goals received a text message encouraging them to reflect on the decision, e.g., "It's OK to have mixed feelings about reducing your alcohol use. Consider making a list of all the reasons you might want to change.”
Even six months after the end of the trial, participants who were exposed to the full text-message intervention reported an average of one less binge drinking day per month as well as a 12% reduced incidence of binge drinking. Neither the control group nor the self-monitoring group had a reduction in alcohol consumption.
"Compared to in-person interventions with a clinician discussing drinking habits with a young adult in the emergency department, which requires time and resources not routinely available, suffers high variability in how it is performed, and has shown limited ability to produce lasting reductions in hazardous drinking among young adults, our text message-based intervention is scalable, provides uniform behavioral materials, and seems to produce meaningful, potentially life-saving results," Suffoletto said. "By interacting with these young adults in a way in which they are receptive to communicating, and reducing the stigma associated with traditional face-to-face counseling, text messages can provide the boost they need to control their drinking when they are at their most vulnerable to forget what is healthiest for them."
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