Jul 222014
 

Pulmonary Embolism Workup in Five Steps.

Acad Emerg Med. 2014 Jul 8;

Authors: Smith CB

Abstract

A workup for pulmonary embolism (PE) is complex, with multiple clinical decision rules to remember. A proper diagnostic workup can safely rule out PE without the use of computed tomography, which is both expensive and exposes patients to radiation and intravenous contrast. However, once PE has been diagnosed, it is important to risk stratify patients according to severity to both treat and disposition them correctly. PQRsTU is a simple, easy-to-remember mnemonic for the workup of PE that considers five phases: PERC phase (PE rule-out criteria), Quantify gestalt phase (to determine proper use of D-dimer or direct to imaging), Risk stratification phase (once PE has been diagnosed), Treatment phase, and Unit or floor (patient disposition). This structured method for evaluating PE will help clinicians develop a systematic, evidence-based approach to this complex and potentially lethal disease. Video is available at https://vimeo.com/91406117 Password: perls.

PMID: 25040049 [PubMed - as supplied by publisher]

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Jul 222014
 

Rapid Response Team Activations Within 24 Hours of Admission From the Emergency Department: An Innovative Approach for Performance Improvement.

Acad Emerg Med. 2014 Jun;21(6):667-672

Authors: Lovett PB, Massone RJ, Holmes MN, Hall RV, Lopez BL

Abstract
OBJECTIVES: Performance improvement programs in emergency medicine (EM) have evolved beyond peer reviews of referred cases and now encompass a large set of quality metrics that are measured proactively. However, peer review of cases continues to be an important element of performance improvement, and selection of cases tends to be driven by an ad hoc referral process based on concerns about problems with care in the emergency department (ED). In the past decade, there has been widespread hospital adoption of rapid response teams (RRTs) that respond to patients who decline clinically to reduce adverse outcomes. In an effort to cast a wider net, to take a more systematic approach, and to avoid "blind spots" from individual variability in criteria for referring cases, the institution instituted a new process for selecting cases for ED peer review based on RRT activations within 24 hours of admission from the ED. The hypothesis was that a formal process for review of these activation cases would increase the number of cases for peer review.
METHODS: This was a prospective, observational study conducted from July 1, 2012, to June 30, 2013, at an urban, academic medical center with an EM residency program. A new automated monthly report was created, capturing all RRT activations within 24 hours of admission from the ED. All events were reviewed by three physicians from the ED performance improvement committee to examine for systems issues, individual provider issues, or both, that might yield opportunities for improvement. Cases with potential opportunities were reviewed by the full ED performance improvement committee. Cases were classified according to the indication for response team activation using the system outlined by the U.S. Agency for Healthcare Research and Quality.
RESULTS: During the study period 61,814 patients were treated in the ED, and 13,067 were admitted to inpatient status. Thirty-two RRT activations within 24 hours of admission from the ED occurred among these admitted patients, representing 0.24% of admissions (95% confidence interval [CI] = 0.16% to 0.33%). Of the 32 cases, only one was also referred independently for ED performance improvement review via the traditional ad hoc process. During the same period of time, 85 cases were referred to the ED performance improvement committee via the traditional ad hoc referral process. Thus, the RRT cases added an additional 31 cases, or 36.5%, to the 85 cases reviewed in ED performance improvement. Of the 32 cases, two were determined by the performance improvement committee to have individual provider factors in their ED care, which contributed to the clinical decline triggering the response teams; none had system factors. Most of the response team activations were for neurologic changes (n = 13) and respiratory status changes (n = 12). In two cases there was long-term morbidity or mortality related to the team activation event; in neither of these cases were ED system or individual provider factors judged to have contributed.
CONCLUSIONS: The review of RRT activations within 24 hours of admission from the ED significantly supplemented the typical ad hoc referral system for peer review of cases, highlighting cases that likely would not have received attention within the ED. This novel and unique case review process revealed opportunities for education and performance improvement. This and other systematic approaches to case detection may be useful adjuncts to traditional case referrals for review.

PMID: 25039551 [PubMed - as supplied by publisher]

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Jul 222014
 

Prevalence of Nonmedical Problems Among Older Adults Presenting to the Emergency Department.

Acad Emerg Med. 2014 Jun;21(6):651-658

Authors: Stevens TB, Richmond NL, Pereira GF, Shenvi CL, Platts-Mills TF

Abstract
OBJECTIVES: Health outcomes among older emergency department (ED) patients may be influenced by physical, economic, and psychological problems not routinely identified during the ED visit. The objective of this study was to characterize such problems among older adults presenting to the ED.
METHODS: This was a prevalence study with enrollment during 4-hour periods randomly selected between 9 a.m. and 9 p.m. on random days of the week over a period of 8 weeks at an academic ED in the southeast United States. Participants were noninstitutionalized, cognitively intact adults aged 65 years or older without life-threatening illness or injury. Consenting patients were asked about the frequency of 10 prespecified problems during the past year.
RESULTS: Patients (N = 138) were non-Hispanic white (69%) and female (57%) and almost all had primary providers (95%) and health insurance (98%). Forty percent reported their overall health as fair (21%) or poor (19%). Hazardous drinking habits were reported by 10% of patients. The prevalence of problems occurring either "sometimes" or "often" in the past year were pain (60%), difficulty walking (47%), lack of money (32%), isolation and loneliness (14%), lack of transportation (12%), difficulty scheduling a doctor's appointment (4%), difficulty getting prescriptions filled (4%), and lack of dental care (6%). Nine patients (7%) reported experiencing physical or psychological abuse at some point in the past year. Females, minorities, and individuals living in urban areas reported higher rates of most problems.
CONCLUSIONS: Nonmedical problems are common among cognitively intact, independent living, non-critically ill older patients presenting to an ED in the southeast United States.

PMID: 25039549 [PubMed - as supplied by publisher]

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Jul 222014
 
Related Articles

First hospitalization for heart failure in France in 2009: patient characteristics and 30-day follow-up.

Arch Cardiovasc Dis. 2013 Nov;106(11):570-85

Authors: Tuppin P, Cuerq A, de Peretti C, Fagot-Campagna A, Danchin N, Juillière Y, Alla F, Allemand H, Bauters C, Drici MD, Hagège A, Jondeau G, Jourdain P, Leizorovicz A, Paccaud F

Abstract
BACKGROUND: The incidence of heart failure (HF) is stable in industrialized countries, but its prevalence continues to increase, especially due to the ageing of the population, and mortality remains high.
OBJECTIVE: To estimate the incidence in France and describe the management and short-term outcome of patients hospitalized for HF for the first time.
METHOD: The study population comprised French national health insurance general scheme beneficiaries (77% of the French population) hospitalized in 2009 with a principal diagnosis of HF after exclusion of those hospitalized for HF between 2006 and 2008 or with a chronic disease status for HF. Data were collected from the national health insurance information system (SNIIRAM).
RESULTS: A total of 69,958 patients (mean age 78 years; 48% men) were included. The incidence of first hospitalization for HF was 0.14% (≥ 55 years, 0.5%; ≥ 90 years, 3.1%). Compared with controls without HF, patients more frequently presented cardiovascular or other co-morbidities. The hospital mortality rate was 6.4% and the mortality rate during the 30 days after discharge was 4.4% (3.4% without readmission). Among 30-day survivors, all-cause and HF 30-day readmission rates were 18% (< 70 years, 22%; ≥ 90 years, 13%) and 5%, respectively. Reimbursements among 30-day survivors comprised at least a beta-blocker in 54% of cases, diuretics in 85%, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in 67%, a diuretic and ACEI/ARB combination in 23% and a beta-blocker, ACEI/ARB and diuretic combination in 37%.
CONCLUSION: Patients admitted for HF presented high rates of co-morbidity, readmission and death at 30 days, and there remains room for improvement in their drug treatments; these findings indicate the need for improvement in return-home and therapeutic education programmes.

PMID: 24140417 [PubMed - indexed for MEDLINE]

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Jul 222014
 
Related Articles

Bacterial etiology of empyema thoracis and parapneumonic pleural effusion in Thai children aged less than 16 years.

Southeast Asian J Trop Med Public Health. 2014 Mar;45(2):442-54

Authors: Lochindarat S, Teeratakulpisarn J, Warachit B, Chanta C, Thapa K, Gilbert GL, Wangroongsarb Y, Pirçon JY, Van Dyke MK, Liu Y, Hausdorff WP

Abstract
This study aimed to identify the bacterial etiology of empyema thoracis or parapneumonic pleural effusions in Thai children, with a focus on pneumococcus. This hospital-based, descriptive study included children aged < or = 16 years, diagnosed with empyema thoracis or parapneumonic pleural effusion, from whom a pleural fluid (PF) sample was taken between January 2008 and November 2009. PF and blood samples were cultured and PF samples were also tested by polymerase chain reaction (PCR) to assess whether evidence of an infection might be identified among culture-negative samples. Serotyping of Streptococcus pneumoniae-positive samples was performed by molecular techniques and Quellung reaction. In this study, 29 children with empyema thoracis and 42 children with parapneumonic pleural effusion were enrolled. Potentially pathogenic bacteria were cultured in 13/71 samples at local or central laboratories; the most common bacteria were Staphylococcus aureus (8 children) and S. pneumoniae (2 children). Molecular techniques detected one or more targeted respiratory pathogens in 18/71 PF samples. S. pneumoniae and Haemophilus influenzae were identified by PCR in 13 and 6 children, respectively; PCR for S. aureus was not performed. The pneumococcal serotypes identified were 1, 3, 5, 6A/B, 9A/V, 14, 15A, 19F and 23A. This study shows that among Thai children with empyema thoracis and parapneumonic pleural effusions, S. aureus and S. pneumoniae were the most common pathogens identified by culture and PCR, respectively. These findings confirmed that molecular techniques are more sensitive for identification of S. pneumoniae and H. influenzae and enhance detection of important bacterial causes of empyema.

PMID: 24968687 [PubMed - indexed for MEDLINE]

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Jul 222014
 
Related Articles

Catheter-related bloodstream infections caused by Trichosporon species.

Southeast Asian J Trop Med Public Health. 2014 Mar;45(2):421-9

Authors: Issarachaikul R, Lertwannawit O, Detporntewan P, Uaprasert N, Plongla R, Shuangshoti S, Chindamporn A, Suankratay C

Abstract
Trichosporonosis is an emerging invasive opportunistic fungal infection in immunocompromised patients. We report 5 catheter related blood stream infections caused by Trichosporon species over a five-year period at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. All the patients were immunocompromised, had received broad-spectrum antibiotics and had a central venous catheter or arterial line inserted for a mean duration of 16.2 days (range 10-30 days). Four patients developed disseminated infection and only 2 survived, giving a mortality rate of 60%. Because of the prevalence of Trichosporon catheter related blood stream infections at our institute, health care providers should have a high index of suspicion for Trichosporon species infections in patients with risk factors and prolonged presence of a central venous catheter.

PMID: 24968684 [PubMed - indexed for MEDLINE]

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