Grand Rounds Recap 4/27

Morbidity and Mortality Conference with Dr. Curry

Palliative Care in the Emergency Department

View fullsize

• Initiating palliative care in the ED can be a hotly debated topic
• The reasons why patients already in palliative care or hospice at home are not entirely clear and likely represent some combination of uncontrolled symptoms, family discordance with plan, family or patient discomfort with the dying process
• One study, Wallace 2013, looked at symptoms that brought patients to the ED and found that most of those presentations could have been avoided with better symptom control at home
• Another article by Grudzen 2012 sought to determine barriers to initiating palliative care in the emergency department and five key themes were identified (table)
• There are some emergency departments with advanced protocols that have been proposed to assist in initiating of palliative care in the ED (Rojas 2016)
• Initiation of palliative care in the ED should, in general, be a rare occurrence.  When you are considering it, keep the following three tenets in mind to maximize success:
  1. Right Patient
     • A patient with a certain prognosis from their disease process which has been clearly evaluated by the specialist in that care area
     • This disease process should be likely to result in the patient's death in the ED (not prolonged)
  2. Right Dynamic
     • You have to have the time and the psychological energy to establish a stronger than normal relationship with the patient and family
     • There should have been some prior engagement with palliative care or end-of-life discussions
     • You must have family buy-in
  3. Right Place
     • You need to have the appropriate physical space for this to occur. The middle of a busy trauma bay is probably not the right place
     • You need to have the appropriate resources to make sure the patient and families needs are attended to
     • Your staff must have appropriate training and comfort level with these types of patients

Open Fracture Management

• Open fractures are generally classified based on the Gustilo classification which was first described in 1976 and expanded with respect to the Type III fractures in 1984
• In the prospective arm of the initial Gustilo study, as well as in Patzakis 1974, very high rates of microbial contamination were documented when the wounds were cultured (though this did not always correlate with actual infection)
• Patzakis 1974 is the primary basis on which we give cephalosporins initially as this group had a statistically significant decrease in wound infections compared to no antibiotics and a penicillin/streptomycin group
• There is a Cochrane review that contains a meta-analysis of the subsequent literature regarding antibiotic use in open fractures indicating that they do decrease infection rates
  • Interestingly, when looking at open finger fractures there was no statistical significance to the benefit; leading the authors to conclude that "antibiotic prophylaxis administered to people with open finger fractures may not reduce the incidence of early infection..."
  • It is also important to note, that the propensity of the studies in the Cochrane review are of isolated long bone injuries and not of hand, wrist or foot injuries

Cognitive Errors in Emergency Medicine

• See our previous post on The Cognitive Autopsy for a full discussion of this topic

Guillan-Barre' Syndrome

• Named for the case report and description by Gillain, Barre' and Strohl in 1916
• Was probably first described in a case report by Landry in 1859
• The disease is best described as an acute immune-mediated polyneuropathy
• Incidence is between 1-2/100,000 cases per year
• There are multiple subtypes, but the most common are...
  • Acute Inflammatory Demyelinating Polyneuropathy
  • Acute Motor Axonal Neuropathy
  • Acute Motor and Sensory Axonal Neuropathy
  • Miller-Fisher Syndrome
  • Etc...
• Symptoms typically develop over days to weeks and typically after some sort of viral-syndrome illness
• AIDP accounts for 90% of cases in the US and Europe
• Features of AIDP are
  • Progressive distal muscle weakness
  • Loss of DTR's
  • Distal parasthesias
  • Pain (25-60%)
  • Dysautonomia
• Diagnosis is typically made by a classic history and/or physical examination and classic LP findings of albuminocytologic dissociation
• Albuminocytologic dissociation (elevated CSF protein without WBC elevation) is on about ~60% sensitive and is even less so early in the disease process
• EMG is the gold-standard for diagnosis
• Treatment involves monitoring respiratory parameters, IVIG or PLEX

Infection in Sickle Cell Disease

• Infection in SCD patients is thought to be due to splenic dysfunction and functional asplenia causes by splenic auto-infarction from sickling episodes
• There is also some component of immunomodulation/immunocompromise through other pathways associated with sickle cell disease
• Though overall mortality in pediatrics patients with sickle cell disease has decreased since 1983 (due to vaccination against encapsulated organisms), sepsis is still the most common cause of mortality
• In adults, bloodstream infections are most commonly catheter-related and most of those are long-term central venous catheters (Chulamokha 2006)
• Multiple other studies (Zurrok 2006 and Jeng 2002) have indicated a high rate of infection in sickle cell patients with a long-term CVC with rates between 1.5-5.5/1000 CVC days which is reported as higher than those undergoing active chemotherapy
• The National Heart, Lung and Blood Institute issued an Expert Panel Report in 2014 for the Evidence-Based Management of Sickle Cell Disease which outlines the treatment of the febrile patient with sickle cell disease
• The bottom line is to beware of sickle cell patients with long-term CVC's and be aware of the risks of infection

Isopropyl Alcohol Ingestion

• Hand sanitizer ingestion has been on the rise in the past decade with increasing case reports of all types of ingestions
• Gormley 2012 documented a rising incidence of intentional ethanol-containing hand sanitizers from 2005-2009 as reported to national poison control centers, but there are many case reports of isopropyl alcohol containing hand sanitizers as well
• Isopropyl alcohol is converted to acetone by alcohol dehydrogenase
• A few facts about isopropyl alcohol ingestion
  • Does NOT cause an anion gap metabolic acidosis (unlike methanol and ethylene glycol)
  • Does cause ketosis/ketonuria (due to acetone but not beta-hydroxybutyrate or acetic acid)
  • Is a potent GI irritant
  • CNS depression is similar or slightly more potent than that of ethanol
  • Massive ingestion can lead to significant hemodynamic instability

---

Ultrasound Guided Nerve Blocks with Dr. Carleton

There are obvious benefits to performing ultrasound-guided nerve blocks vs procedural sedation for applicable procedures which include the avoidance of respiratory/CNS depression, aspiration risk, and altered mental states in already altered patients

There is evidence comparing nerve blocks head-to-head with procedural sedation showing lower ED length of stay, improved safety profile, and decreased complications

There is significant evidence that suggests that, with the right training platform, that nerve blocks are safe and effective in the hands of emergency department providers--our platform is still under development. 

Though overall complications are relatively rare, the potential for significant nerve-block-related complications certainly exists and include:

• Intraneural injection. Injecting even relatively small amounts of anesthetic within a nerve can lead to its complete and sometimes irreversible damage
  • One study showed the incidence of permanent peripheral nerve damage to be 1.5/10k procedures
• Local Anesthetic Systemic Toxicity (LAST) can result when local anesthetic is accidentally injected into the arterial system. A keen awareness of where the needle tip is at all times as well as a strong awareness of the regional anatomy is essential at all times during these procedures
• Again, a fortified knowledge of the surrounding anatomy is critical as unintended consequences of the procedure may result with successful anesthesia. The most salient example would be successful anesthesia via a interscalene approach in which C5 (controlling the phrenic nerve and diaphragm) is anesthetized along with C6 and C7. Studies support that 100% of the time using the interscalene approach at least some degree of C5 is affected.
• For a review of how to perform an interscalene brachial plexus block, check out this link from NYSORA for an in-depth procedural briefing and this link for a video review from NYSORA
• For a review of how to perform a supraclavicular brachial plexus block, check out this link from NYSORA for an in-depth procedural briefing and this link for a video review from NYSORA

---

The Patient Experience with Dr. Shewakramani

One poll shows that >50% of ED physicians believe that Press-Ganeys have led to worse quality care, particularly with respect to the excessive prescribing of narcotic pain medications and antibiotics as physicians strive to meet patient expectations and make them happy

The perception that greater patient satisfaction is correlated with worse mortality outcomes comes from the Fenton study. In this study, correlation was shown, though causation not in the least, with much room left open for confounders. 

Some important truths about Press-Ganey:

• Press Ganey is part of the concept of Value-Based Purchasing (VBR), made salient in part by the Affordable Care Act. The purpose of VBR is to tie government reimbursement of medicare/medicaid to quality care as defined by the government. A portion of that reimbursement is specifically tied to Press-Ganeys/patient satisfaction. 
• Patients who are discharged with mental health and substance abuse diagnoses are excluded from the survey, as are patients younger than 18 years old, who leave without being seen, who are prisoners, and who are homeless
• The ED-specific portion of Press-Ganey, ED CAHPS, is a 63 questionnaire that was supposed to be unrolled earlier this year. Look out for it on the horizon. Four of those 63 questions are physician specific. 
• Press Ganey data is published on line and available for public access

Take home points from Dr. Shewakramani: Don't change your practice to affect your scores, change your approach!

• Studies show that happy patients = happy physicians, and vice versa, and they feed upon one another in a positive feedback loop. So how do we help us help you be happy?
• Realize what patients are looking for:
  • Studies show that what patients want most out of their ED visit are short wait times and adequate communication between staff and patient 
  • Studies show that patients are NOT less satisfied if they have an expectation to receive narcotic pain medications and/or antibiotics as long as they recieve a sufficient explanation of why they are not receiving them
• Tips from Dr. Shewakramani to improve the patient experience:
  • Shake hands, introduce yourself, sit down, make an effort to facilitate patient privacy, and do what you can to minimize interruptions during the encounter
  • Explain your thought process to your patients in plain language. This can be an opportunity for you to go through your mental model aloud which may be helpful to you as well. In his words: "Think loudly and thoughtfully."
  • Explain delays in the process

Ultimately, happier physicians make happy patients, and happy patients are shown to adhere to their medical plans more and litigate less. Happy physicians experience burn-out less.