September 2018

Authors

Andy Neill
Dave McCreary

Clinical Question

Do we alter our decision making when we are treating patients in corridors

Paper

Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey

Background

Hey there’s no space in this ED – presumably yours is the same. Crowding is quite literally everywhere. Any cupboard is a reasonable patient assessment area. The suspicion is that we act and make different decisions when things are like this. We suspect this is bad. Sometimes when patient’s companions are present we find ourselves uncomfortable and perhaps making different decisions. This paper looks at this

Methods

This was a voluntary survey conducted at ACEP at one of the booths manned by an academic institution
The questions were carefully thought about and had been piloted locally before hand
They had to answer 22 questions

Results

– 400 EPs completed it (6000 go to ACEP)
– most reported that they altered practice in either crowding or a patient accompanying them
– of the people who reported altering their behaviour over a 1/3 reported problems from it
– the failures were as expected – things we don’t like to talk about (psych, GU, IPV, trafficing…) and examining the naughty bits

Thoughts
– in terms of level of evidence this lies somewhere above late night ranty tweeting and below that of actual observational data
– there are huge risks of bias here – “wait you want me to fill out your survey about how everything makes my job more difficult – sign me up…”
– all that being said we all know this is true. The only people who say that they never alter practice in terms of hallway care are the type of people who never actually see any patients at all (we all know them…).
– It needs said again that as much as we want to be fast we have to fight with both other staff and even the patients to make sure we’ve done a proper assessment
– However blaming folk for making alterations in practice due to crowding is like blaming kids with cholera for drinking the dirty water – there often isn’t a realistic choice here. This is one of the (many) reasons why crowding kills.

Authors
Eoghan Colgan
Stuart Watson

This first appeared on the St Mungos Podcast and is used here with permission. you can find out more by visiting stmungos-ed.com

Clinical Question

How useful is qSOFA for detecting critical illness in septic ED patients?

Title of Paper

Comparison of qSOFA with current emergency department tools for screening of patients with sepsis for critical illness

Journal and Year

EMJ. 2018

Lead Author

Robert Rodriguez

Background

* Sepsis is bad
* Early identification of the sicker patients is the cornerstone of sepsis management
* Until recently our established criteria for defining sicker patients was SIRS, Sepsis, Severe Sepsis and Septic Shock
* Boat was rocked by introduction of the quick Sequential Organ Failure Assessment (qSOFA) criteria for identification of patients outside of the ICU with potential to do badly:
* Systolic Blood Pressure ≤ 100mmHg
* RR ≥ 22
* Altered Mental Status (GCS<15)
* Score of ≥2 thought to be high risk of poor outcomes (≥10% mortality)
* Not expressly developed for ED screening, but has since be proposed as such
* Developed in heterogeneous group including patients outside of ED
* Primary outcome of derivation / validation was mortality – not the only outcome of interest in ED management
* Mortality at 30 days is longer than general outcome of interest for ED
* Triage decisions in the ED patient with sepsis are expected to anticipate the need for ICU care and mortality over shorter time from presentation, such as within 72 hours

Patients Studied

Adult ED patients admitted to hospital with infectious disease related illness

Study Design

Multicentre, retrospective cohort study

Methods

Comparison:
qSOFA versus SIRS/Sepsis/Severe Sepsis criteria and lactate levels

Primary Outcome

Critical illness – ICU stay, receipt of vasopressor support, hospital death (excluding hospice and DNAR) – within 72 hours of presentation

Summary of Results

* 3743 patients analysed
* Median 58 years
* Hospital mortality 1.9% with median 5 days to death
* “SIRS/Sepsis” criteria 58.8%, “Severe Sepsis” criteria 29%
* qQOFA: ≥1 49.1%, ≥2 16.7%, 3 3.9%
* Lactate: ≥2 34.4%, ≥4 7.9%

* Primary outcome: 13.7% patients
* 96.3% admitted to ICU
* 42.8% vasopressors
* 8.8% died

Sensitivity
Specificity
NLR
qSOFA ≥1
86.1%
56.7%
0.24
qSOFA≥2
53.5%
89.1%
0.52
qSOFA≥3
17.6%
98.3%
0.84
SIRS/Sepsis
86.7%
45.6%
0.29
Severe Sepsis
69.7%
77.5%
0.39
Lactate ≥2
61.5%
71.6%
0.54
Lactate ≥4
26.6%
96.0%
0.77

* qSOFA had a significantly better AUROC (0.788 vs 0.754 for SIRS and 0.763 for lactate – p0.0026 & <0.001)
* Removal of vasopressor from the outcome (because hypotension in the qSOFA might have favoured this):
* ≥1 sensitivity 86.6%, specificity 56.6%
* ≥2 sensitivity 54.0%, specificity 89.0%

Authors Conclusion

qSOFA criteria had better performance for predicting early critical illness than SIRS, sepsis or severe sepsis criteria or lactate levels. Given that qSOFA criteria are easy to perform without the need for blood tests, they may be preferred over current ED risk stratification tools in the ED.

Clinical Bottom Line

qSOFA is really easy to do, particularly in ED. This study would suggests it functions at least as well as, probably better than the old criteria of infection/SIRS/Sepsis/Severe Sepsis etc.

Authors

Mark Winstanley

This interview was recorded at the RCEM Spring CPD conference in Spring 2018

Authors

Ed Snelson
Nikki Abela

This interview was recorded at PEM Fest in 2018 in Birmingham

Authors

Dave McCreary
Andy Neill

Clinical Question

Can MRI pick patients for thrombolysis with no onset time?

Title of Paper:
MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset

Journal and Year

NEJM. May 2018.
Lead Author:

Thomalla et al.
Background:

Current thrombolysis guidelines recommend treating patients within 4.5 hours of onset
Many people (up to 27% of strokes) have no clear onset time, usually as they wake up with the symptoms (we all see them come in at the end of our night shifts)
Some of those patients may well be within a salvageable thrombolysis window
MRI in stroke patients with known onset time has shown visible ischaemia with absence of hyper intense signal in the same region on fluid-attenuated inversion recovery (FLAIR), to be predictive of onset within 4.5 hours
In DWI, abnormal water (like CVA associated oedema) is bright, and this happens really early
FLAIR is MRI physics magic which can show lesions like ischaemia but changes take longer to show
This trial looks at whether thrombolysing these patients improves functional outcomes

Study Design

Multi-centre, randomised, double-blind, placebo controlled trial
70 centres, 8 European countries
Experienced stroke research centres with routine use of alteplase and could perform urgent stroke MRI

Patients Studied

Adult stroke patients (18-80 years) with NIHSS <25 Independent of ADLs prior to stroke Stroke symptoms on waking or couldn’t report onset time >4.5 hours since patient last known to be well
Mismatch between abnormal signal on diffusion-weighted imaging and no visible signal change on FLAIR
Excluded: NIHSS >25, ICH, lesions >1/3 territory of MCA, planned thrombectomy, contraindications to alteplase

Intervention

Alteplase thrombolysis (0.9mg/kg with 10% as bolus & remainder infused over 60 minutes)

Comparison

Matched placebo

Outcomes

Primary efficacy end point: Favourable clinical outcome – 0 or 1 on modified Rankin scale at 90 days
Primary safety end points: death and composite death/dependence (MR 4-6) at 90 days

Summary of Results

Stopped enrolment 300 short of sample size target due to anticipation of loss of funding
503 patients randomised (aimed for 800)
254 (alteplase) vs 249 (placebo)
Median NIHSS 6 at baseline
89% patients (both groups) had no onset time due to waking with symptoms
Median time to treatment from symptom recognition 3.1hrs (alteplase) vs 3.2 hrs (placebo)
Median time from known well to symptoms 10.3 vs 10.4 hrs

Efficacy Outcome: (Modified Rankin <2 at 90 days)
53.3% (alteplase) vs 41.8% (placebo) (adjusted OR 1.61 [95%CI 1.09 – 2.36; p=0.02])
11% diference – they were powered to find 10%
Safety Outcome: (death or disability at 90 days)
13.5% (alteplase) vs 18.3% (placebo) (adjusted OR 0.68 [95%CI 0.39-1.18; p=0.17])
Death: 4.1% (alteplase) vs 1.2% (placebo) (adjusted OR 3.38 (95%CI 0.92-12.52; p=0.07])

Authors Conclusion

Among patients with acute stroke and an unknown time of symptom onset who had MRI findings of an ischaemic lesion of diffusion weighted imaging but no parenchymal hyperintensity in the corresponding region on FLAIR, IV thrombolysis with alteplase resulted in better functional outcome that treatment with placebo.

Clinical Bottom Line

If only we all had access to emergency MRI…
Other #FOAMed Resources / References:

Radiopaedia explains FLAIR
Andy explains all things thrombolysis in stroke on emergencymedicineireland.com