The Clinical Respiratory Score: investigating the reliability of an asthma scoring tool across a multidisciplinary team.

BACKGROUND: Asthma scoring tools are used by emergency department (ED) teams to communicate severity of illness. Although most have been validated, none has been found to be sufficiently valid to allow for use across a multidisciplinary team managing pediatric asthma exacerbations. OBJECTIVE: We sought to evaluate the inter-rater reliability of the Clinical Respiratory Score (CRS) among all members of an ED care team. DESIGN/METHODS: We conducted a retrospective study of children aged 2 to 18 years presenting with an acute asthma exacerbation to an urban pediatric ED over a 2-year period. We determined reliability using two CRS measurements independently documented by two separate providers, 15 min apart. An inter-class correlation coefficient (ICC) was calculated to determine overall reliability among users. Subgroup analysis was conducted to determine reliability between types of providers and the six components of the CRS. RESULTS: A total of 9,749 patient encounters were identified and 1,562 (16%) met our inclusion criteria. The majority of score pairings (n = 1096, 70.2%) were documented by a registered nurse followed by a respiratory therapist. The overall reliability of the CRS, when documented by two providers, was acceptable with an ICC of 0.76 (95% CI: 0.74-0.78, p < 0.001). Removing CRS components with the lowest agreement did not affect the overall ICC when re-calculated. CONCLUSION(S): The CRS is a reliable asthma severity scoring tool for pediatric patients presenting with an acute asthma exacerbation when utilized across care team members. Simplifying the CRS by removing the color and mental status components did not affect its reliability.

Impact of a Pediatric-Focused Communication Course on Patient/Caregiver-Perceived Physician Communication Skills in a Pediatric Emergency Department.

OBJECTIVES: To evaluate the impact of a pediatric-focused, relationship-centered communication course on patient/caregiver assessment of emergency department (ED) physician communication skills. METHODS: This was a prospective study; a previously validated assessment tool (Pediatric Physician Interpersonal Communication Skills Assessment [P-PICSA]) was used to collect pediatric patient/caregiver evaluation of ED physician communication skills. Emergency department physicians were required to attend a 5.5-hour communication course. Differences in precourse/postcourse P-PICSA and top-box scores were analyzed to determine course impact on ED physician communication skills. RESULTS: From July 2016 to August 2017, 49 pediatric ED physicians participated in the course, and 24 physicians (49%) had 6-month precourse/postcourse P-PICSA data. Postcourse scores were higher for all 13 items, with 3 items achieving statistical significance: (1) the doctor used words I could understand; (2) the way the doctor involved me in making decisions about my child's care in the ED; (3) how the doctor discussed next steps and/or follow-up plans for my child's care after we leave the ED (P < 0.05). Additionally, postcourse, top-box score percentages were higher for 12 items, with 1 item achieving statistical significance (P = 0.0386). CONCLUSIONS: An organization-wide, pediatric-focused, relationship-centered communication course improved patient/caregiver-perceived ED physician communication. Further research is necessary to assess long-term sustainability.

Quantifying the impact of novel metastatic cancer therapies on health inequalities in survival outcomes.

Background: Novel therapies in metastatic cancers have contributed to improvements in survival outcomes, yet real-world data suggest that improvements may be mainly driven by those patient groups who already had the highest survival outcomes. This study aimed to develop and apply a framework for quantifying the impact of novel metastatic cancer therapies on health inequalities in survival outcomes based on published aggregate data. Methods: Nine (N = 9) novel therapies for metastatic breast cancer (mBC), metastatic colorectal cancer (mCRC), and metastatic non-small cell lung cancer (mNSCLC) were identified, 3 for each cancer type. Individual patient data (IPD) for overall survival (OS) and progression-free survival (PFS) were replicated from published Kaplan-Meier (KM) curves. For each cancer type, data were pooled for the novel therapies and comparators separately and weighted based on sample size to ensure equal contribution of each therapy in the analyses. Parametric (mixture) distributions were fitted to the weighted data to model and extrapolate survival. The inequality in survival was defined by the absolute difference between groups with the highest and lowest survival for 2 stratifications: one for which survival was stratified into 2 groups and one using 5 groups. Additionally, a linear regression model was fitted to survival estimates for the 5 groups, with the regression coefficient or slope considered as the inequality gradient (IG). The impact of the pooled novel therapies was subsequently defined as the change in survival inequality relative to the pooled comparator therapies. A probabilistic analysis was performed to quantify parameter uncertainty. Results: The analyses found that novel therapies were associated with significant increases in inequalities in survival outcomes relative to their comparators, except in terms of OS for mNSCLC. For mBC, the inequalities in OS increased by 13.9 (95% CI: 1.4; 26.6) months, or 25.0%, if OS was stratified in 5 groups. The IG for mBC increased by 3.2 (0.3; 6.1) months, or 24.7%. For mCRC, inequalities increased by 6.7 (3.0; 10.5) months, or 40.4%, for stratification based on 5 groups; the IG increased by 1.6 (0.7; 2.4) months, or 40.2%. For mNSCLC, inequalities decreased by 14.9 (-84.5; 19.0) months, or 12.2%, for the 5-group stratification; the IG decreased by 2.0 (-16.1; 5.1) months, or 5.5%. Results for the stratification based on 2 groups demonstrated significant increases in OS inequality for all cancer types. In terms of PFS, the increases in survival inequalities were larger in a relative sense compared with OS. For mBC, PFS inequalities increased by 8.7 (5.9; 11.6) months, or 71.7%, for stratification based on 5 groups; the IG increased by 2.0 (1.3; 2.6) months, or 67.6%. For mCRC, PFS inequalities increased by 5.4 (4.2; 6.6) months, or 147.6%, for the same stratification. The IG increased by 1.3 (1.1; 1.6) months, or 172.7%. For mNSCLC, inequalities increased by 18.2 (12.5; 24.4) months, or 93.8%, for the 5-group stratification; the IG increased by 4.0 (2.8; 5.4) months, or 88.1%. Results from the stratification based on 2 groups were similar. Conclusion: Novel therapies for mBC, mCRC, and mNSCLC are generally associated with significant increases in survival inequalities relative to their comparators in randomized controlled trials, though inequalities in OS for mNSCLC decreased nonsignificantly when stratified based on 5 groups. Although further research using real-world IPD is warranted to assess how, for example, social determinants of health affect the impact of therapies on health inequalities among patient groups, the proposed framework can provide important insights in the absence of such data.

Does crowding influence emergency department treatment time and disposition?

OBJECTIVE: The objective of this study was to determine whether crowding influences treatment times and disposition decisions for emergency department (ED) patients. METHODS: We conducted a retrospective cohort study at 2 hospitals from January 1, 2014, to July 1, 2014. Adult ED visits with dispositions of discharge, admission, or transfer were included. Treatment times were modeled by linear regression with log-transformation; disposition decisions (admission or transfer vs discharge) were modeled by logistic regression. Both models adjusted for chief complaint, Emergency Severity Index (ESI), and 4 crowding metrics in quartiles: waiting count, treatment count, boarding count, and National Emergency Department Overcrowding Scale. RESULTS: We included 21,382 visits at site A (12.9% excluded) and 29,193 at site B (15.0% excluded). Respective quartiles of treatment count increased treatment times by 7.1%, 10.5%, and 13.3% at site A (P < 0.001) and by 4.0%, 6.5%, and 10.2% at site B (P < 0.001). The fourth quartile of treatment count increased estimates of treatment time for patients with chest pain and ESI level 2 from 2.5 to 2.9 hours at site A (20 minutes) and from 3.0 to 3.3 hours at site B (18 minutes). Treatment times decreased with quartiles of waiting count by 5.6%, 7.2%, and 7.3% at site B (P < 0.001). Odds of admission or transfer increased with quartiles of waiting count by 8.7%, 9.6%, and 20.3% at site A (P = 0.011) and for the third (11.7%) and fourth quartiles (27.3%) at site B (P < 0.001). CONCLUSIONS: Local crowding influenced ED treatment times and disposition decisions at 2 hospitals after adjusting for chief complaint and ESI.

Communication Course for Pediatric Providers Improves Self-efficacy.

BACKGROUND: Communication is essential to building a trusting, clinician-patient relationship. Multiple studies have demonstrated the effects of experiential communication training on patient experience and provider well-being and resiliency. To date, no studies have described an organization-wide communication training program for pediatric clinicians. The objective of this study was to evaluate the impact of a pediatric-focused communication course on provider satisfaction, self-efficacy, and burnout. METHODS: Texas Children's Hospital, in collaboration with the Academy on Communication in Healthcare, designed and implemented a pediatric focused communication course entitled Breakthrough Communication. Pre, immediate-post, and 3-month postcourse completion online surveys were sent to participants 1 day before, 1 day after, and 3 months after course completion. Participant demographic information, self-assessment of communication skills, the Maslach Burnout Inventory Human Services Survey, and postcourse satisfaction data were collected. RESULTS: Participants reported high course satisfaction and improved self-efficacy in all measured skill sets both following and 3 months after course completion. Trends indicating a reduction in provider burnout improved in 2 of the 3 Maslach Burnout Inventory domains; however, statistical significance was not achieved. CONCLUSIONS: A pediatric-focused communication course was well received by multi-specialty clinicians within a large, academic health care organization. This course enhanced clinician self-efficacy with newly learned pediatric encounter specific communication skills.

Outcomes of severe sepsis and septic shock patients after stratification by initial lactate value.

BACKGROUND: In the setting of severe sepsis and septic shock, mortality increases when lactate levels are ≥ 4 mmol/L. However, the consequences of lower lactate levels in this population are not well understood. The study aimed to determine the in-hospital mortality associated with severe sepsis and septic shock when initial lactate levels are < 4 mmol/L. METHODS: This is a retrospective cohort study of septic patients admitted over a 40-month period. Totally 338 patients were divided into three groups based on initial lactate values. Group 1 had lactate levels < 2 mmol/L; group 2: 2-4 mmol/L; and group 3: ≥ 4 mmol/L. The primary outcome was in-hospital mortality. RESULTS: There were 111 patients in group 1, 96 patients in group 2, and 131 in group 3. The mortality rates were 21.6%, 35.4%, and 51.9% respectively. Univariate analysis revealed the mortality differences to be statistically significant. Multivariate logistic regression demonstrated higher odds of death with higher lactate tier group, however the findings did not reach statistical significance. CONCLUSION: This study found that only assignment to group 3, initial lactic acid level of ≥ 4 mmol/L, was independently associated with increased mortality after correcting for underlying severity of illness and organ dysfunction. However, rising lactate levels in the other two groups were associated with increased severity of illness and were inversely proportional to prognosis.

The Incidence and Outcome Differences in Severe Sepsis with and without Lactic Acidosis.

INTRODUCTION: To compare the incidence, characteristics, and outcomes of lactate expressors and nonexpressors in patients with severe sepsis and septic shock. METHODS: This is a retrospective cohort study of patients with severe sepsis and septic shock who presented over a 40-month period to an academic tertiary care center. Primary outcome of interest was in-hospital mortality. Secondary outcomes were hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, and escalation of care. RESULTS: Three hundred and thirty-eight patients met inclusion criteria and were divided into a lactate expressor group (n = 197; initial lactate ≥2.5 mmol/L) and a nonexpressor group (n = 141; lactate <2.5 mmol/L). The mortality rate was 46.2% for lactate expressors and 24.8% for nonexpressors. There were no significant differences in hospital or ICU LOS. The escalation-of-care rate in the severe sepsis nonexpressor group was more than double that found in the expressor group: 16.5% versus 6.2% (P = 0.040). The two groups had baseline differences: expressor group had a higher median Acute Physiology and Chronic Health Evaluation II (APACHE II) illness severity score, and nonexpressors had an increased prevalence of comorbid conditions. APACHE II score (odds ratio [OR] 1.10 (1.07-1.14), P < 0.001) and being in the expressor group (OR 1.72 [1.03-2.89], P = 0.039) increased the odds of mortality. CONCLUSIONS: In patients with severe sepsis and septic shock, lactate nonexpressors are common. Although the mortality in this cohort is less than its counterparts who present with lactate elevation, it is still significant which warrants vigilance in their care.

Iodinated contrast prior to thrombolysis was not associated with worse intracranial hemorrhage.

OBJECTIVES: The objective was to assess relative incidence of clinical adverse effects between patients receiving, and not receiving, iodinated contrast prior to thrombolysis. METHODS: This was a retrospective registry review of patients presenting to the emergency department treated with recombinant tissue-type plasminogen activator (rt-PA) for acute ischemic stroke between 2004 and 2012. The authors compared the occurrence of all grades of intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage (sICH), and in-hospital deaths between patients undergoing computed tomographic angiography (CTA) prior to thrombolysis and those who did not. RESULTS: A total of 1,014 patients were available for analysis meeting inclusion criteria. A total of 473 patients underwent CTA prior to rt-PA administration. Baseline characteristics were generally similar across groups, excepting fewer signs of acute infarct and old stroke in the CTA group (28.8% vs. 8.5% and 9.9% vs. 3.7%, respectively) and creatinine. Adverse event outcomes were not consistently distributed across the groups. Patients in the CTA group had a similar incidence of any ICH (11.0% vs. 8.1%, p = 0.120), but fewer type II parenchymal hemorrhages (2.1% vs. 4.6%, p = 0.025) and fewer in-hospital deaths (7.2% vs. 12.6%, p = 0.005). CONCLUSIONS: No consistent harms were observed in association with intravenous iodinated contrast prior to rt-PA administration. It is reasonable to continue CTA prior to thrombolysis as clinically indicated.

Outcomes of Patients Requiring Blood Pressure Control Before Thrombolysis with tPA for Acute Ischemic Stroke.

INTRODUCTION: The purpose of this study was to assess safety and efficacy of thrombolysis in the setting of aggressive blood pressure (BP) control as it compares to standard BP control or no BP control prior to thrombolysis. METHODS: We performed a retrospective review of patients treated with tissue plasminogen activator (tPA) for acute ischemic stroke (AIS) between 2004-2011. We compared the outcomes of patients treated with tPA for AIS who required aggressive BP control prior to thrombolysis to those requiring standard or no BP control prior to thrombolysis. The primary outcome of interest was safety, defined by all grades of hemorrhagic transformation and neurologic deterioration. The secondary outcome was efficacy, determined by functional status at discharge, and in-hospital deaths. RESULTS: Of 427 patients included in the analysis, 89 received aggressive BP control prior to thrombolysis, 65 received standard BP control, and 273 required no BP control prior to thrombolysis. Patients requiring BP control had more severe strokes, with median arrival National Institutes of Health Stroke Scale of 10 (IQR [6-17]) in patients not requiring BP control versus 11 (IQR [5-16]) and 13 (IQR [7-20]) in patients requiring standard and aggressive BP lowering therapies, respectively (p=0.048). In a multiple logistic regression model adjusting for baseline differences, there were no statistically significant differences in adverse events between the three groups (P>0.10). CONCLUSION: We observed no association between BP control and adverse outcomes in ischemic stroke patients undergoing thrombolysis. However, additional study is necessary to confirm or refute the safety of aggressive BP control prior to thrombolysis.