Crash Cart: Admission rates, EM apps, antibiotic prescribing, and cockroaches in skulls

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This week: Is your hospital’s admission rate the reason healthy patients die? Plus, more steps are suggested for your antibiotic prescribing. Join in as our editors discuss the week’s headlines.

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A hospital’s admission rate is the life and death factor for healthy patients visiting the ED

“‘We restricted the sample to people who shouldn’t be dying. People who are generally healthy, who don’t have serious illnesses like cancer, who aren’t [old],’ says Dr. Ziad Obermeyer. And they found that about 10,000 people die each year in that first week after being sent home from the ER—the majority of them after visiting hospitals that admitted the least number of patients.” Original Article by Time.

E. Paul DeKoning, MD, MS: Even at a “high-cost, big academic hospital”, I still occasionally have to duke it out to get patients admitted. While certainly not with every patient, it is becoming more common. I’ve found the challenge the greatest when the admitting doc is trying to simultaneously wear both the care management hat and the hospitalist hat. Both are vital, but in my mind they tend to be competing interests and at the end of the day patients can suffer. One is seemingly designed to keep patients out of the hospital; the other exists to admit them. The article is accurate in describing our job: we make decisions with a paucity of time and data. It also alludes to, but doesn’t clearly state the challenges non-EM trained providers at smaller, rural hospitals face every day. Our rural non-EM trained colleagues perform a vital service to patients and do an amazing job caring for the patients in our region, but EM training is very different. By design.

Ryan McKennon, DO: Hard to know what to do with this information. There are so many variables here.  First, all OBS patients were classified based on ultimate disposition, so if the patient was transferred to OBS and discharged 23 hours later, that counts as a discharge not an admission. I think most of us would consider this to be an admission for the purposes of a study like this (e.g. chest pain rule out). Second, this just looked at ER discharge mortality, not overall mortality. Thus, if the patient was admitted and died in house or sent home after the admission and died within a week of the ER visit, that death was not counted. From the study : “Hospitals with the lowest admission rates had inpatient mortality 3.4 times lower (95% confidence interval 3.2 to 3.7) than the highest.” So are we just changing the location of death or preventing it by the admission? Certainly if further studies can identify which patients are sent home that would have benefited from an admission THAT would be very useful, but I’m just not sure how this study changes my practice.

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Need more EM apps on your phone? iMedicalApps has a list for you.

iMedicalApps published a list of 15 not-so-obvious apps that they believe every EP should have. Original Article by iMedical Apps.

E. Paul DeKoning, MD, MS: Oy. Another sign that I’m getting old: the last thing I need is to spend more time on my phone. I’m pretty confident that I don’t need more apps. I very confident that I don’t need one for gout. I seldom use the myriad of apps I’ve downloaded over the years and I think I basically need two: a drug reference and a calculator of various “scores”, e.g. HEART, PECARN, etc. If I need to look the other stuff up, I’ll do it at my workstation. I’m looking forward to the day when doctors don’t actually need to know anything but can just look it up on their phones.

Ryan McKennon, DO: I’m with Paul, give me less apps that do more, not more apps. MDCalc and Epocrates are the only ones I use.

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In regards to antibiotic prescribing, you need to be more involved in understanding the consequences

According to the Cochrane Review – “Restrictive techniques centered on guidelines and regulations aimed at limiting antibiotic prescribing while enabling measures aimed at improving the quality of prescribing, including providing advice and feedback to help physicians make more targeted prescribing decisions. Both were designed to increase appropriate decision making, so only patients likely to benefit from antibiotics received them.” Original Article by Medscape.

E. Paul DeKoning, MD, MS: Sounds good on paper. A bit more challenging in the ED when culture data is rarely available and we routinely treat infections empirically and/or broadly. Our hospital restrictive guideline has “prescribed from the ED” as an “out”. One good starting place is continued efforts to not prescribe in those conditions that don’t need antibiotics at all: routine strep pharyngitis, many cases of acute otitis media, acute bronchitis, etc.

Ryan McKennon, DO: I would like to see something like this focused more on the outpatient setting. Certainly inpatient antibiotics stewardship is important but we just don’t have all the information needed to implement most of these inpatient programs.

William Sullivan, DO, JD: The whole premise behind this study just irks me. The researchers state that “prescribers need to be involved in understanding the consequences of their intervention, good and bad.” Really? How ironic. Oh, and let’s rub it in a little more by quoting a bunch of “studies” showing how “physicians in hospitals often prescribe unnecessary antimicrobials, thereby raising the risk for nosocomial infections from antibiotic-resistant bacteria.” Also ironic that the “studies” didn’t show any concrete proof of changes in outcome when antibiotic use was curtailed. Mortality was the same. There was “low certainty evidence” about reducing C. diff infections, and decreased antibiotic use “likely” (not “definitively” mind you) shortened hospital stays by 2 days. But … did those same “studies” look at how some government website tracks whether we give antibiotics for any whisp of an abnormality on a chest x-ray that anyone at any time determines is a “pneumonia” in a patient’s hospital admission … and then calls us bad doctors if we DON’T prescribe antibiotics? And we just can’t prescribe any antibiotics for that “pneumonia,” we have to prescribe DOUBLE REGIMENS for many of the patients while simultaneously throwing them into pulmonary edema by giving them two gallons of IV fluid if their bloor pressure should happen to dip below 90 or if their lactate should happen to hit the magical value of 4. So this current study will give us just what we need – more interventions to address the unintended consequences from the prior interventions that have already been so thoughtfully imposed upon us. Want to put automatic stop orders on antibiotic prescriptions? Be my guest. Want to give us rapid microbial testing results? I’m all for it. Formulary restrictions will do nothing except changing the antibiotics being prescribed and selecting resistance for a new set of drugs. Requiring experts to approve my choices will make me put the orders in under the expert’s name so the expert is responsible for the outcome. When will “studies” start looking at the cause of these problems rather than ineffectively attempting to deal with the effects of the problems? This is why I trust fewer and fewer “studies” these days.

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Coming to your ED: a cockroach inside a patient’s head

“The woman knew after waking up suddenly in the middle of the night that the pain in her head — which had an itchy, scratchy feel to it — couldn’t be normal. Boy was she ever right. A trip to the hospital yielded the cause — doctors pulled a live cockroach from her skull.” Original Article by CNN.

E. Paul DeKoning, MD, MS: That seems like a problem. Another reason I’m not a big fan of cockroaches.

Ryan McKennon, DO: Really more inside her nose then in her “skull” but still. *shiver* Time to start sleeping with a mask on I guess…

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