Detecting Sepsis in an Emergency Department: SIRS vs. qSOFA.

Sepsis is a condition that can progress to serious illness and even death. The diagnosis of sepsis is difficult because no unique biomarker exists. With this, health care providers must rely on clinical diagnostic criteria to guide diagnosis. Systemic Inflammatory Response Syndrome (SIRS) criteria have been used for diagnosis since 1992. The more recent attempt to replace SIRS with the quick Sequential Organ Failure Assessment (qSOFA) for assessment of potentially septic patients is troublesome. The qSOFA was designed as a prognostic and not diagnostic tool. Using established processes of evidence-based medicine, it is shown herein that qSOFA fails to meet the definition of a diagnostic assessment tool. Thus, the SIRS assessment should remain the gold standard tool for detecting patients at risk of "sepsis."

Rapid Systematic Review: The Appropriate Use of Quick Sequential Organ Failure Assessment (qSOFA) in the Emergency Department.

BACKGROUND: The concept of sepsis has recently been redefined by an International Task Force. The task force recommended the use of the quick Sequential Organ Failure Assessment (qSOFA) score instead of Systemic Inflammatory Response Syndrome (SIRS) criteria to identify patients at high risk of mortality from sepsis outside of the intensive care unit, including in emergency departments (EDs). However, the primary outcome for qSOFA is prediction of risk for mortality, which is not the principal outcome measure considered in the ED. From the ED perspective, the priorities are the identification (diagnosis) of the septic patient and then the initiation of time-sensitive, life-saving interventions. METHOD: We performed a structured review of PubMed from January 2012 to December 2018, limited to reports involving human subjects and written in English language and containing relevant keywords. The highest-quality studies were then reviewed in a structured format. We utilized these studies to estimate the sensitivity and specificity of SIRS and qSOFA for diagnosis of sepsis. RESULTS: Thirteen unique articles were identified for further review, and the 11 highest-grade articles (C and D) were determined to be appropriate for inclusion in this review, and the two low-grade articles were excluded (E). CONCLUSIONS: Based on multiple retrospective and few prospective studies, it appears that qSOFA performs poorly in comparison with SIRS as a diagnostic tool for ED patients who may have sepsis or septic shock. However, qSOFA does have a strong prognostic accuracy for mortality in those ED patients already diagnosed with sepsis or septic shock.

Rapid Systematic Review: Age-Adjusted D-Dimer for Ruling Out Pulmonary Embolism.

BACKGROUND: Pulmonary embolism (PE) is a disease diagnosed relatively frequently in emergency departments (EDs). Evidence suggests that improved decision making may decrease inappropriate testing, unnecessary radiation exposure, and non-beneficial treatment. Several studies have looked at the utility and safety of age-adjusting the D-dimer levels used to safely rule out PE. OBJECTIVE: This rapid systematic review sought to answer the question: Can an age-adjusted D-dimer be used to safely rule out PE in patients over 50 years old? METHODS: We performed a structured review of PubMed from January 2012 to January 2018 limited to reports involving human subjects and written in the English language and containing relevant keywords. The highest-quality studies were then reviewed in a structured format. RESULTS: One hundred and eleven papers were identified for further review. Eight articles were determined to be appropriate for inclusion in this summary. These studies all used patient age (in years over 50) × 10 µg/L (fibrinogen equivalent units) as their definition of an age-adjusted D-dimer. CONCLUSIONS: Age-adjusted D-dimer cutoff values, in combination with a non-high clinical probability, is safe and effective to essentially rule out PE in ED patients.

Resident Access to the St. Louis County Prescription Drug Monitoring Program: Why PDMPs Matter and How to Gain Access.

Prescription Drug Monitoring Programs (PDMPSs) permit physicians to determine whether patients obtained addictive substances from multiple physicians or pharmacies. In April 2017, the Saint Louis County Department of Public Health created its own PDMP. This manuscript evaluates evidence regarding the efficacy of PDMPs, in addition to discussing their impact on patient care and a provider's workflow. It also details how physicians can register to use the St. Louis County PDMP, Missouri's de-facto PDMP.

Rapid Systematic Review: Intra-Arterial Thrombectomy ("Clot Retrieval") for Selected Patients with Acute Ischemic Stroke.

BACKGROUND: Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality. However, precisely defining the optimal treatment for individual patients early after AIS onset remains elusive. There has recently been a surge in published studies documenting the effectiveness of mechanical intra-arterial thrombectomy for treatment of a subset of patients with AIS. This therapy has been proposed and studied for the small (<1.2%) subgroup of patients with ischemic strokes who have "large vessel" strokes or strokes that fail to improve after the administration of tissue plasminogen activator (t-PA). The current rapid systematic review provides practicing emergency physicians updated information regarding mechanical thrombectomy as a treatment option for carefully selected AIS patients. METHODS: A PubMed literature search was conducted from January 1996 to June 2016 and limited to human clinical trials written in English with relevant keywords. High-quality randomized controlled studies identified then underwent a structured review. RESULTS: In total, 179 papers fulfilling the search criteria were screened and 8 appropriate articles were rigorously reviewed in detail and recommendations given on the effectiveness and indication of mechanical intra-arterial thrombectomy for the treatment of AIS. CONCLUSIONS: Mechanical intra-arterial thrombectomy reduces long-term disability in a properly selected subset of patients who have an AIS caused by large vessel occlusion. Many of these patients will have failed to improve after intravenous administration of t-PA, and mortality is not increased when combined with t-PA. Careful screening criteria should be in place to identify the limited subset of patients to whom this therapy is delivered to derive optimal treatment benefits.

Nurses' accuracy and self-perceived ability using the Emergency Severity Index triage tool: a cross-sectional study in four Swiss hospitals.

BACKGROUND: The Emergency Severity Index (ESI) is an English language emergency department patient triage tool. After translation, it has been adapted for use to triage patients in growing numbers of emergency departments in non-English-speaking countries. Few reports of the proficiency of triage nurses to score an ESI exist. We sought to determine accuracy, inter-rater reliability, and subjective confidence of triage nurses at four hospitals to determine an ESI from standardized ESI scenarios. METHODS: Triage nurses assigned an ESI score to each of 30 standard ESI (ESI Implementation Handbook Version 4) translated teaching case scenarios. Accuracy and Inter-rater reliability (Krippendorff's alpha) of the ESI scoring was measured. Nurses' subjective confidence applying the ESI algorithm was obtained by a Likert scale. RESULTS: Sixty-nine nurses from four EDs participated in the study. They scored 59.6 % of the case scenarios correctly. Inter-rater reliability was 0.78 (Krippendorff's alpha). Most (54/69, 78 %) felt confident in their ability to apply the ESI. CONCLUSIONS: Low accuracy of ESI score assignment was observed when nurses scored an ESI for 30 standard written case scenarios, translated into nurses' native language, despite a good inter-rater reliability and high nurse confidence in their ability to apply the ESI. Although feasible, using standard written case scenarios to determine ESI triage scoring effectiveness may not be the optimum means to rate nurses' triage skills.

Quantifying federal funding and scholarly output related to the academic emergency medicine consensus conferences.

PURPOSE: Every year since 2000, Academic Emergency Medicine (AEM) has presented a one-day consensus conference to generate a research agenda for advancement of a scientific topic. One of the 12 annual issues of AEM is reserved for the proceedings of these conferences. The purpose of this study was to measure academic productivity of these conferences by evaluating subsequent federal research funding received by authors of conference manuscripts and calculating citation counts of conference papers. METHOD: This was a cross-sectional study. In 2012, the NIH RePORTER system was searched to identify subsequent federal funding obtained by authors of the consensus conference issues from 2000 to 2010. Funded projects were coded as related or unrelated to conference topic. Citation counts for all conference manuscripts were quantified using Scopus and Google Scholar. Simple descriptive statistics were reported. RESULTS: Eight hundred fifty-two individual authors contributed to 280 papers published in the 11 consensus conference issues. One hundred thirty-seven authors (16%) obtained funding for 318 projects. A median of 22 topic-related projects per conference (range 10-97) accounted for a median of $20,488,331 per conference (range $7,779,512 to $122,918,205). The average (± SD) number of citations per paper was 15.7 ± 20.5 in Scopus and 23.7 ± 32.6 in Google Scholar. CONCLUSIONS: The authors of consensus conference manuscripts obtained significant federal grant support for follow-up research related to conference themes. In addition, the manuscripts generated by these conferences were frequently cited. Conferences devoted to research agenda development appear to be an academically worthwhile endeavor.