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.

Prospective analysis of the effect of physician experience with the FAST examination in reducing the use of CT scans.

OBJECTIVE: The objective of this study was to examine the effect of ultrasound experience level on emergency physicians' Focused Assessment with Sonography for Trauma (FAST) exam accuracy and emergency physicians' confidence in using FAST findings to assist in managing patients with blunt trauma. METHODS: This prospective, consecutive enrolment study evaluated adult trauma team activation blunt trauma patients. Based on the number of post-training FAST exams carried out, 11 attending emergency physicians were grouped into A (<25 exams, n = 4), B (26-50 exams, n = 4) or C (>50 exams, n = 3). The FAST exam was carried out prior to other diagnostic studies. The emergency physicians were asked to prospectively judge their perception of the need for surgery, abdominal CT or no further tests. All study patients ultimately underwent CT, diagnostic peritoneal lavage or laparotomy. Among each physician group, the number of subsequent CT scans deemed necessary by the emergency physician after a 'normal' FAST was calculated and compared. RESULTS: Accuracy was greatest in group C. Sixty-nine of 80 patients in group A had a normal FAST exam; emergency physicians deemed CT necessary in 68/69 cases (99%; confidence interval [CI] 92-100%). Eighty-two of 98 patients in group C had a normal FAST exam; emergency physicians deemed CT necessary in 19/82 cases (23%; CI 15-34%). Physicians in groups B and C were less likely to order CT after a normal FAST than group A (P < 0.001). CONCLUSIONS: FAST accuracy was greatest among more experienced emergency physicians. A normal FAST exam assisted more experienced emergency physicians with the perceived need to order significantly fewer CT scans than less experienced emergency physicians.

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.

Drug interactions in at-risk emergency department patients.

OBJECTIVES: Many emergency department (ED) patients are at risk for drug interactions (DIs) because they are elders, and/or they have chronic illnesses requiring treatment with multiple medications. In the ED, medications may be added to complex treatment regimens without the benefit of screening for DIs. Emergency physicians may therefore cause DIs, or miss the opportunity to intervene against a pre-existing DI. Prior studies are contradictory regarding whether DIs are more likely to be due to medications administered or prescribed in the ED or medications prescribed elsewhere. Screening for DIs using computer software, such as that done by retail pharmacies, is now a standard of practice, and is done more frequently than when these other DI studies were reported during the previous decade. The authors monitored DIs among a focused, at-risk outpatient ED population, to test the hypothesis that ED-induced DIs have become the most common DIs in this population-at-risk. METHODS: A retrospective convenience sample of 200 at-risk patients seen at a tertiary teaching hospital on selected dates of service was analyzed. Eligible patients were ED outpatients aged 60 years or more taking three or more medications, or any age taking five or more medications. Micromedex Drug-Reax software identified DIs. DIs had to represent "major" or "minor" severity, and have "excellent" or "good" literature documentation, to be scored as positive. Pre-existing versus ED-induced DIs were compared by chi-square. DIs were stratified by patient age and by number and type of medications taken. RESULTS: The 200 outpatients (125 female, 75 male) had a mean age (+/-SD) of 64.5 (+/-17.6) years and were taking an average of 7.2 medications. Seventy-nine pre-existing DIs were noted, occurring in 50 of the 200 patients studied. One hundred forty patients received a new medication during their ED visit. Seven new DIs (one in each of seven patients) occurred among these 140 patients. DIs were less frequently caused by medications added during the ED visit (chi(2) = 22.2, p < 0.001). Digoxin and warfarin were the sources of the greatest number of DIs. CONCLUSIONS: ED outpatients in the at-risk group frequently present with pre-existing DIs. Medications initiated in the ED are a less frequent cause of DI in this group. Medication screening during an ED visit could complement the role of outpatient pharmacies and potentially improve ED patient safety. DIs are most frequently due to digoxin and warfarin in these patients.

Cervical infections in emergency department patients with vaginal bleeding.

UNLABELLED: To the best of the authors' knowledge, no previous study has compared the prevalences of Chlamydia trachomatis (CT) or Neisseria gonorrhoeae (NG) cervical infection among pregnant and non-pregnant patients presenting to the emergency department (ED) with vaginal bleeding. OBJECTIVES: To determine the prevalence of these infections in a simultaneously assembled cohort, and to determine whether pregnancy is associated with altered rates of CT or NG cervical infection among patients with vaginal bleeding. METHODS: This was a prospective, seven-month, cross-sectional study of a convenience sample of patients (aged > or = 15 years) who presented to an urban, teaching ED with the chief complaint of vaginal bleeding. A urine pregnancy test was administered to each patient. Cervical swab specimens were analyzed for CT or NG via polymerase chain reaction technology (DNA probe). The hospital laboratory's baseline 18% rate of positive tests was used for sample size planning. Chisquare analysis and Fisher's exact test, where appropriate, were used to compare pregnant and non-pregnant patient groups. RESULTS: Cervical infection rates did not differ between pregnant and non-pregnant patients. Testing for CT showed that 13 of 114 (11%) of the pregnant patients were positive, while 11 of 147 (8%) non-pregnant patients tested positive (chi(2) = 0.759, p = 0.384). Testing for NG revealed that seven of 114 (6%) pregnant patients tested positive, while 16 of 147 (11%) non-pregnant patients tested positive (chi(2) = 1.256, p = 0.262). Combined testing showed that 18 of 114 (16%) of the pregnant patients and 25 of 147 (17%) of the non-pregnant patients harbored a cervical infection with one or both pathogens (chi(2) = 0.009, p = 0.925). CONCLUSIONS: The prevalence of CT or NG cervical infection in pregnant patients presenting to the ED with vaginal bleeding is 16%. Pregnant and non-pregnant patients with vaginal bleeding are at similar risks for having CT or NG cervical infection. Cervical swab specimens should be obtained in all patients with vaginal bleeding.