Evolution of Stroke Diagnosis in the Emergency Room

From Cerebrovascular Diseases:

Background: Access to acute neurological care is limited. Especially in nonurban areas, and owing to uncertainties in diagnosing stroke, non-neurologists often misinterpret stroke symptoms. We evaluated the profile of patients with suspected stroke and the accuracy of the admission diagnosis ‘stroke’ in the setting of a specialized neurological emergency department in a nonurban region.

Methods: In this prospective observational study, (1) data from all 4,174 patients with the discharge diagnosis ‘stroke’ and (2) data from 1,800 consecutive patients (3 cohorts per year over 3 years) with the admission diagnosis ‘stroke’ were included over a 3-year period.

Results: The positive predictive value of the admission diagnosis ‘stroke’ was 0.34; the negative predictive value was 0.97. The rate of misdiagnosis significantly correlated with age and time from symptom onset to presentation. During the study period, the proportion of patients with the admission diagnosis ‘stroke’ admitted early after symptom onset increased from 19.9 to 27.8% within 3 h and from 26.4 to 32.7% within 4.5 h, respectively. Thrombolysis rates increased (from 9.4 to 15.4%).

Conclusion: The uncertainties in interpreting stroke symptoms and the lack of facilities for treating emergency stroke in nonurban areas may be outweighed by offering access to a specialized neurological emergency room, thus rectifying any misinterpretation of stroke symptoms and shortening in-hospital time windows for treatment. Still, the rate of misdiagnosis is high, requiring expensive resources, despite the constant flow of information to the public. Therefore, more prospective data comparing different emergency room settings are needed which focus in particular on patients with the admission diagnosis ‘stroke’.

The Measurement of Time to First Antibiotic Dose for Pneumonia in the Emergency Department: A White Paper and Position Statement Prepared for the American Academy of Emergency Medicine

From the Journal of Emergency Medicine:

Background: Measurement of time to first antibiotic dose (TFAD) in the emergency department (ED) in community-acquired pneumonia (CAP) has been controversial.

Objective: To evaluate original articles reporting outcomes in CAP patients before and after TFAD measurement and assess whether it increases antibiotic overuse in non-CAP conditions.

Methods: We performed searches using PubMed, addressing two questions: 1) Is the measurement of TFAD associated with improved outcomes in CAP? and 2) Is the measurement of TFAD associated with antibiotic overuse or interventions that could result in overuse in non-CAP conditions? Two independent reviewers assessed studies addressing these questions.

Results: Eight studies were identified. All were Grade C or D and of“Adequate” quality: two studies supported TFAD by showing improved outcomes (improved survival in one study and no survival difference but shorter hospital length-of-stay in the second) in CAP patients after the implementation of TFAD; one neutral articlereported no difference in survival with improved TFAD timing; five studies opposed TFAD either by showing increases in antibioticoveruse in non-CAP patients, or suggesting that TFAD measurement would promote antibiotic misuse.

Conclusion: Given inconsistent evidence to demonstrate that improving TFAD in CAP improves outcomes or that TFAD is associated with antibiotic overuse, a Class C indication has been assigned (not acceptable/not appropriate) for EDTFAD measurement. The American Academy of Emergency Medicine recommends that measurement of TFAD in CAP be discontinued.

PTSD for NICU Parents

From the NY Times:

A new study from Stanford University School of Medicine, published in the journal Psychosomatics, followed 18 such parents, both men and women. After four months, three had diagnoses of P.T.S.D. and seven were considered at high risk for the disorder.

In another study, researchers from Duke University interviewed parents six months after their baby’s due date and scored them on three post-traumatic stress symptoms: avoidance, hyperarousal, and flashbacks or nightmares. Of the 30 parents, 29 had two or three of the symptoms, and 16 had all three.

“The NICU was very much like a war zone, with the alarms, the noises, and death and sickness,” Ms. Roscoe said. “You don’t know who’s going to die and who will go home healthy.”

Experts say parents of NICU infants experience multiple traumas, beginning with the early delivery, which is often unexpected.

“The second trauma is seeing their own infant having traumatic medical procedures and life-threatening events, and also witnessing other infants going through similar experiences,” said the author of the Stanford study, Dr. Richard J. Shaw, an associate professor of child psychiatry at Stanford and the Lucile Packard Children’s Hospital.

“And third, they often are given serial bad news,” he continued. “The bad news keeps coming. It’s different from a car accident or an assault or rape, where you get a single trauma and it’s over and you have to deal with it. With a preemie, every time you see your baby the experience comes up again.”

Dell EHR, Part 2

From the NY Times:

On Thursday, Dell, the personal computer maker, plans to join the scramble in earnest, announcing its plan to form a partnership with hospital groups around the country to offer electronic health records — hardware, software, consulting services and financing — to their affiliated physicians. Dell, like the other players, sees the big opportunity as being in offices with 10 doctors or fewer, where three-fourths of the nation’s physicians practice medicine.

Dell plans to act as the hardware supplier and general contractor, working with partners like eClinicalWorks, a maker of electronic health record software, and Perot Systems for data-center hosting, if the medical groups outsource that task.

Dell already has pilot projects under way with a few hospital groups, including Memorial Hermann Healthcare System in Houston and Tufts Medical Center in Boston. This year, Dell announced it was teaming up with Sam’s Club, a division of Wal-Mart, to offer the hardware, software and services for electronic health records to doctors in small practices.

“The technology has to be a simplified, affordable package for physicians,” said Jamie Coffin, general manager of Dell’s health care business. “We’re really going after this market in a concerted way.”

USA Today ER Series: Readmissions

From USA Today:

Readmission is not unique to the Charlottesville medical center, though. A recent New England Journal of Medicine study reported that on average, almost one in five Medicare beneficiaries who are discharged from a hospital will re-enter it within a month. Some are planned, but the majority are not.

Young says unplanned readmissions often come back through hospital emergency departments, and research suggests such hospital visits drain billions from the health care system annually. But many hospitals are working on turning that statistic around, Young adds. And the issue has garnered attention from the Obama administration, which has proposed health care reform that would include lowering readmissions.

“Readmissions are in general a very complicated issue,” says Nancy Foster, vice president for quality and patient-safety policy for the American Hospital Association.

Two Milk Jugs: Cheap Improv Dummy for CPR Practice

I mentioned this a couple iof days ago, but thought I’d post the Medgadget version (which also includes Ian’s video)…

Without a proper dummy, training CPR techniques can be a bit suboptimal, which means people might know the basic methodology but haven’t actually practiced chest compressions. Ian Miller, an ER nurse in Canberra, Australia, suggests using two empty 2 liter (quart) plastic milk jugs as a basic replacement for a CPR dummy.