Grand Rounds Recap 4.25.18

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W. Brian Gibler Visiting Professor Series: "Improving Adherence to Guidelines Before Others Try to Improve it for Us" WITH DR. ALI RAJA

Background

  • There has been a move towards evidence-based medicine over the course of the last 20 years.
  • It behooves us as Emergency Medicine Physicians to move towards evidence-based practice and guidelines.  It is also important that we as Emergency Physicians are the ones spearheading these efforts, otherwise we might find guidelines and recommendations imposed on us by outlying groups.  
  • It can be difficult to persuade physicians to change entrenched practice patterns.  However, there are strategies that can be used to help improve physician adherence to guidelines.

Strategies for Improving Physician Adherence:  Pulmonary Embolism as Example

  • Problem:  Pulmonary Embolism (PE) is a potentially deadly diagnosis, with high mortality and high risk of litigation for missed PEs.  As a result, there has been a significant increase in diagnostic testing.  Studies have subsequently shown that while the incidence of PE has increased (likely because we're finding more of them) the mortality has not decreased.  This suggests that while we may be finding a lot of incidental or inconsequential PEs, and subjecting more patients to the risk of anti-coagulation without any mortality benefit. How can we better educate physicians and guide the use of diagnostic testing for PE?
  • Strategies:
    • Tailoring your Communication Style for Your Audience
      • People have many different communication styles.  By knowing the communication style of your audience, you can improve how well a message or concept is received and perceived.
      • The DISC Personality and Communication Profile is commonly used tool.  Divides people into 4 different communication styles:
        • D:  Dominance
        • I:    Influence
        • S:  Steadiness
        • C:  Conscientiousness
      • By having people in your work group / practice / department, etc all undergo some standardized assessment and figure out their communication style, you can improve the communication and relations within your group.  
    • Clinical Decision Making Tools:  Many clinical decision making tools/scores exist.  Organizing them into a standard approach / risk stratification can help steer towards judicious use and allocation of diagnostic testing.
      • Developed a clinical decision making support tool for PE.
      • Made it readily available within EMR.
      • Implementation decreased use of CTPA within the department.
    • Examination of Individual Practice Patterns:  
      • Several metrics were collected for each physician through EMR.
      • Looked at:
        • Individual physician adherence to evidence based guidelines.
        • Amount of CTPAs ordered, as well as how many were positive for PE.
      • Showed results to physicians individually as well as how they compared to the rest of the physician group.
      • This was also performed with MRI in back pain, length of stay, etc.
      • Works well for data driven physicians.
      • *While this can work well, it is always important to present this information along with a balanced metric to prevent physicians from trying to game the system.  For instance, if you only look at "length of stay" it may encourage physicians to be less thorough in the interest of shortening their length of stay times.  By also measuring a balanced metric such as a "Rate of return visits" for a particular physician, there will be disincentive to try to play towards one specific metric

Strategies for Making Change Outside of Your Institution

  • Participate in National Discussion
    • Participate in national discourse regarding national performance measures
      • Center for Medicare and Medicaid Services (CMS) has created measures that all hospitals who receive reimbursement from Medicare and Medicaid must report
      • Data is publicly available
      • New measures are proposed and approved annually
      • By participating in the discussion we can impact what measures are implemented
      • Example:
        • Outpatient Performance Measure 15 (OP 15) was born out of a study that noticed a large variation among providers with regard to the use of Head CT in headache.  
          • Multi-disciplinary team including neurologists and other specialties came up with this measure, which largely only looked at Head CT utilization (The amount/frequency with which it is ordered)
          • This presents a problem, because it did not take into account the clinical context or reasoning.  It was also implemented by a group that may not be familiar with the Emergency Medicine practice environment.
        • A discourse was started, first with a published editorial titled "Decreasing use of high-cost imaging: the danger of utilization-based performance measures," followed by a study titled "Assessment of Medicare's imaging efficiency measure for emergency department patients with atraumatic headache" which essentially concluded that OP 15 was not reliable or accurate, and may produce misleading findings.  
        • OP 15 was subsequently rejected by the National Quality Forum (NQF).
    • Submit measures to the National Quality Forum
      • Submitting measures to the NQF is not prohibitively difficult.
      • Basically requires a few key components:
        • Measure Description
        • Numerator Statement
        • Denominator Statement
        • Exclusions
      • If there is a topic that might be worth looking at nationally and having that data available, this might be a good avenue.
  • Consider approaching/involving other specialties

Summary

  • If we want change, it should be an EM led effort:
    • We should be driving the research
    • We should be creating the guidelines
    • We should be pushing the evidence

W. Brian Gibler Visiting Professor Series: "Navigating Academic Emergency Medicine" WITH DR. ALI RAJA

Introduction:

  • Lecture aimed at discussing lessons learned with regards to leadership and life in academics during residency as well as throughout career in academics.
  • Some points were inspired by "Simone's Maxims," written by Dr. Joseph V. Simone.  This is a collection of accumulated and lessons and maxims "accumulated over years of personal experience and many mistakes, as well as occasional revelations, both personal and borrowed from others," and is a good read for anyone considering a career in academics.  The original article can be found here.

Lessons Learned in Leadership:

  • Recruitment:  "In Recruiting, First-Class People Recruit First-Class People; Second-Class People Recruit Third-Class People." - Simone
    • Effort goes a long way in recruiting and building a solid team
    • With regards to residency recruitment, applicants notice the difference in an interview day that is attended only by the program director and a few residents compared to one where they meet the chair, vice chair, etc.  A little extra investment can pay dividends.
  • Mentorship and Sponsorship:  There are distinct differences between a coach, a mentor, and a sponsor.  While mentorship has gotten a lot of traction in the literature recently, sponsorship is also extremely important.  
    • Coach:  Somebody who talks to you, tells you what to do.
    • Mentorship:  Talks WITH you.  Discusses your goals
      • Can help you to take first step into area of interest
      • May require some hand holding on part of mentor
      • Can come in many forms:  Traditional research mentor, peer mentor, etc
    • Sponsorship:  A sponsor talks ABOUT you.  Finds opportunities for you.  Acts as an advocate.
      • These are people who will open doors for you
      • Can ask a mentor to serve as a sponsor, but don't necessarily need to be a mentor
      • If you are in a position to advocate for somebody, be a sponsor
      • Can often help with networking, job placement, etc.

***Ideally, you will have all 3 in your career***

  • Getting Involved:  "Members of Most Institutional Committees Consist of About 30% Who Will Work at It, Despite Other Pressures, and 20% Who Are Idiots, Status Seekers, or Troublemakers." - Simone
    • Many people have been part of committees where not everyone contributes, and who may be motivated solely by the title or resume boost.
    • If you are part of a committee, work at it.  
    • If you want something done, surround yourself with the right people.
  • Be a National Expert AND a Local Expert
    • As people progress through their careers, become an expert on a topic, they may be invited to speak nationally, participate in widely read or distributed projects, etc.
    • Often times people back out of commitments and decrease their involvement in their local shops to create time for these "larger scale projects."
    • It's important to maintain your foundation:
      • Keeps you in touch with the subject matter.
      • Reminds you why and how you got to the national stage in the first place.
      • People will respect your input and advice on a topic more if you remain clinically relevant and involved at your own institution.
  • When Considering a Position:  "The Longer and More Detailed the Written Offer to a New Faculty Recruit, the More Likely Both Sides Will End Up Unhappy." - Simone
    • If you ever find yourself needing > 2-3 pages in a letter of commitment consider if that is a place you want to be.
    • If it takes 20-25 pages of clauses and stipulations for two parties to come to an agreement, the likelihood is that neither party will end up happy.  
    • Keep it simple and concise.  You are entering a relationship, and a lot of that is built on trust.  Do not feel the need to have a clause for every minor detail or possible instance.  
  • Burnout and Resiliency
    • Huge topic in medicine in general.  Emergency Medicine has been shown to have high rates of burnout relative to other specialties.  
    • Incentives and tokens have not been shown to be too effective in combating burnout (Pay increases, perks, etc).  People accommodate quickly.  Adjusting compensation may not have lasting effect.
    • Instead, important to focus on physician engagement:
      • Getting people involved will help them feel invested.
        • Encourage participation in committees
        • Involve them in recruitment
        • Assign mentors and mentees with similar interests
      • Physicians who feel empowered and invested may be less likely to burnout.
  • Be Adaptable
    • Ability to change and adapt with the times is essential in academic medicine.
    • By being open to and willing to make changes, you can succeed in a number of different areas.

Morbidity and Mortality Conference WITH DR. LAUREN TITONE

Malignancy with SIRS

Background:  

  • Early antibiotic administration in sepsis has been shown to decrease mortality
  • Delay in antibiotic administration has been shown to directly correlate with worsening mortality
    • In immunocompetent patient:  8% Increase in mortality for every hour prior to antibiotic administration.
    • In immunocompromised patient (Such as those with malignancy undergoing treatment):  Mortality is increased as much as 18% for every hour prior to antibiotic administration.  
  • Early antibiotic administration is key, though recognizing sepsis in the immunocompromised patient can prove problematic.

Diagnostic Challenges:

  • Clinical presentation of sepsis may not be as evident in immunocompromised or neutropenic patients.  Common findings such as fever and even local leukocyte reaction may not be present as patient is less able to mount a response.  For this reason, there is a trend in guidelines and recommendations to recognize "Malignancy with SIRS" as opposed to the classic "Neutropenic fever", as fever might not be a reliable finding.  
  • Study examining the clinical presentation of common infections in patients with severe neutropenia (Compared patients with ANC > 100 and < 100) showed that neutropenic patients are less likely to present classically.
    • UTI:  Neutropenic patients with urinary tract infections were less likely to have classic diagnostic features
      • WBC on microscopic urinalysis were only found in 11% of patients with culture proven UTI.
      • Only 33% had urinary frequency.
      • Only 44% had dysuria
    • Similar findings with pneumonia, with fewer patients in the neutropenic group presenting with cough, sputum production, etc.
  • Laboratory studies assessing for true neutropenia have also been shown to delay antibiotic administration, which directly correlates with increased mortality.

Approach to Diagnosis and Management:

  • Consider aggressive management for any patient with history of malignancy who meets SIRS criteria.
  • Check out our decision making algorithm here.
  • Goal is to have antibiotics administered within 1 hour of presentation.  Some international guidelines aim for a window of 30 minutes.  
  • Having a standardized approach such as the one in the outline in the link above can help to improve recognition and rapid initiation of treatment.

Learning Points:

  • Maintain a high suspicion of sepsis in patients with history of malignancy and recent chemotherapy who present with vitals consistent with SIRS criteria.
  • Order antibiotics prior to establishing a firm diagnosis of neutropenia or source of infection.
  • Utilize resources accordingly.

Severe Cutaneous Drug Reactions (SCAR):   ABCDs Mnemonic

A:  Acute Generalized Erythematous Pustulosis (AGEP)

  • History:  Usually starts hours to days after medication is started (80-90% are caused by antibiotics).
  • Lesion:  Non-follicular pustules on a background of erythema.
  • Location:  Starts in the skin folds (Neck and Underarms).
  • Associated Findings:  Fever, leukocytosis, neutrophilia.  Solid organ involvement in 20% of cases.
  • Treatment:  Remove offending agent, symptomatic treatment and topical steroids.

B:  Bullous Disease  (Bullous pemphigoid and Pemphigus vulgaris)

  • History:  Insidious onset.
  • Lesion:  Blisters ranging in size.  May be flaccid or tense depending on whether it's bullous pemphigoid or pemphigus vulgaris.
  • Location:  Can occur anywhere.
  • Associated Findings:  Can lead to secondary infection if extensive.
  • Treatment:  Remove offending agent, symptomatic treatment and topical steroids.

C:  ACE Inhibitor Induced Angioedema

  • History:  Occurs secondary to ACE inhibitor use.  Can occur at any time, may not only occur when first starting the medication.

D:  Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS Syndrome)

  • History:  Usually occurs 2-6 weeks after exposure.  Common offenders include AEDs, sulfonamides, and allopurinol. 
  • Lesions:  Morbiliform rash.  Facial edema can occur in up to 50%, as well as scaling and purpura.  Rash may progress to an exfoliative dermatitis. 
  • Location:  Typically begins on the face and upper extremities initially.  Usually involves >50% BSA.  Consider DRESS highly if a rash covers >50% of the body.  Mucous membrane involvement occurs in nearly 1/2 of patients, and usually occurs at a single site.  
  • Associated Findings:  Fever, leukocytosis characterized by an atypical lymphocytosis in 30-70% as well as an absolute eosinophilia in 50-60%.  Hepatitis can occur in up to 80-90%, though the laboratory abnormalities can be mild.  Diagnostic range for DRESS is an ALT > 2X the upper limit of normal, or Alk Phos > 1.5X the upper limit of normal.  Multiple organ systems can be affected, and 50-60% will have multiple organ systems involved.  
  • Treatment:  Remove offending agent, months of high dose steroids.

S:  Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)

  • History:  7-21 days following drug exposure.  One of the first presenting signs is pain in the skin.
  • Lesions:  Dusky macules, atypical target lesions, erosions, sloughing, and mucous membrane involvement.
  • Location:  Can be extensive.  If <10% involvement, diagnosed as SJS.  If > 30%, TEN.
  • Associated Findings:  Fever, lymphadenopathy, hepatitis, and cytopenias.
  • Treatment:  Remove offending agent, supportive care, +/ IVIG or cyclosporine.

Take Aways:

  • When considering an adverse drug reaction rash, consider the ABCDE'S Mnemonic.
  • Patients may look septic.  Consider adverse drug reactions in septic appearing patients already on antibiotics.
  • In patients who present with rash, consider ordering labs to check for organ involvement.
  • "Run of the mill" drug rashes will usually occur less than 2 weeks after exposure.

Acute on Chronic Liver Failure

Acute liver failure:  New elevation in INR > 1.5 is the sole diagnostic criterion. Common causes include acetaminophen overdose, drug induced, and viral etiologies.

  • Viral causes
    • Hepatitis A:  Can cause acute liver failure.  Usually a food borne illness (fecal-oral transmission)
    • Hepatitis B:  ALF rare in otherwise healthy patients.  Infection is usually more severe if underlying liver disease, especially if concomitant hepatitis D infection.  30% of patients develop scleral icterus.  
    • Hepatitis C:  Rare to see acute liver failure in hepatitis C as it is usually an indolent course. 
    • Hepatitis E:  Can cause acute liver failure, especially in pregnancy.

Acute on Chronic Liver Failure (ACLF):  Loosely defined, though there are some definitions being put out in Asian-Pacific Guidelines as well as some US and European societies.  Definition is fairly loose currently, and includes acute jaundice and coagulopathy in the setting of chronic liver disease.  Diagnostic laboratory testing includes total bili, MELD score, INR.  LFTs can be less reliable as they may be chronically elevated, as well as chronically low with marginal response in chronic disease. 

Take Away: 

  • Cannot blame acute liver failure on chronic disease.
  • Consider a broad differential.
  • ACLF has a significant mortality.

Women and ACS

Background:  Early foundational studies in ACS excluded women.  There also exists a cognitive bias that ACS is a male predominant disease, and therefore ACS is not the predominant pathology to worry about in women.  

Clinical Presentation:

  • Women are more likely to present with "atypical" clinical symptoms:  Shortness of breath, fatigue, sleep disturbance, isolated diaphoresis.  Women are also more likely to present with multiple complaints.
  • Young women are also much more likely to present without frank chest pain.
  • Women are 2X more likely to have non-occlusive CAD.  This means that risk stratification studies are more likely to be negative (stress test, cath) prior to occlusive event.

Impact:  Because young women are less likely to present typically, they are less likely to be hospitalized, and revascularized.  Women therefore have increased mortality rates compared to males of similar age. 

Take Aways:

  • Consider ACS, especially in young women with risk factors who present with vague symptoms.
  • Consider serial EKGs
  • Non occlusive CAD is more common in women, and may not play by the rules.

R4 Clinical Soap Box Lecture Series: Ultrasound in Cardiac Arrest WITH DR. AALAP SHAH

Background:  Cardiac arrest remains a challenging topic in healthcare, as it is extremely difficult to study.  There has been some good data showing high quality CPR is important, shocking early in shockable rhythm is good, but for everything else there's not great evidence. So what can we do to improve it?

Ultrasound in Resuscitation:

  • Diagnostic Information:  
    • Using ultrasound to assess for cardiac activity.  (Electrical activity on the monitor does not necessarily equate to mechanical cardiac activity)
    • Not all PEA is created equal.
      • 55% of the time is actually "Psuedo-PEA" with organized cardiac activity that is not generating a palpable pulse.
      • Pseudo PEA generally represents severe cardiogenic shock, and has a survival rate of 37.7%
      • True PEA without cardiac activity has a lower survival rate of 17.9%
  • Guide to Intervention:
    • Can help determine cause of PEA:  Pneumothorax, pericardial effusion, RV dilation concerning for PE, etc.
    • Can help guide intervention:  PEA with cardiac activity (Pseudo PEA) is more likely to respond to IV medications (epi, etc)
  • Prognostication:
    • Those with cardiac activity on US have higher rates of ROSC
    • Patients without cardiac activity have lower rates of survival, but not 0. 
  • Utility in Real Time:  
    • Transthoracic ultrasound can lead to increased time off the chest.
    • Use of Transesophageal echo in the setting of CPR can have several benefits:
      • Can help guide compressions
        • Studies have shown that typical location for chest compressions "Between the nipples" can actually lead to compression of the aorta and outflow tracks decreasing the efficacy of CPR.
        • US can lead to real time guidance on where to compress the chest.
      • Real time cardiac monitoring
        • Can monitor continuously without having to refine windows.
        • Can guide resuscitation.
        • Minimize time off the chest.

R3 Taming the SRU Lecture Series:  Myxedema Coma and Cardiac Arrest WITH DR. ROBERT WHITFORD

Myxedema Coma

Cause:  Deficient thyroid hormone

  • Primary:  Disease of the thyroid
  • Secondary:  Decreased pituitary synthesis of TSH
  • Tertiary:  Disease of hypothalamus (Central)

Clinical Presentation:  Symptoms:  Common presenting symptoms include altered mental status, bradycardia.  hypothermia, hypotension, and hypo-ventilation. Severe disease can also lead to arrhythmia and heart failure.

Diagnosis: 

  • TSH:  May be elevated in primary hypothyroidism.  Will be low in secondary and tertiary.
  • Hyponatremia is common due to decreased thermogenesis. 
  • Hypoglycemia can also occur usually secondary to concomitant adrenal insufficiency.  

Management:  

  • Replete thyroid hormone.
  • Important to give hydrocortisone as well, as adrenal insufficiency commonly occurs with myxedema coma. 
  • Supportive measures.

Ultrasound in Arrest

  • Can help guide compressions
  • Determine etiology
  • Detect cardiac activity that might not be detected on monitor
    • Patient was in fine V-Fib read on the monitor as asystole
  • Pro tip:  When doing transthoracic ultrasound, take a clip and review it after resuming compressions to minimize time off of the chest.