I agree with the authors that using the guidelines may not avoid
subdiaphragmatic viceral injuries. First, many underlying diseases could
alter the thorax shape and the diaphragm position. Second, in patients
using positive mechanical ventilation support, many different ventilatory
strategies, such as lung recruitment strategy, can alter the diaphragm
level.
Moreover, among some special groups of patients, such as patie...
I agree with the authors that using the guidelines may not avoid
subdiaphragmatic viceral injuries. First, many underlying diseases could
alter the thorax shape and the diaphragm position. Second, in patients
using positive mechanical ventilation support, many different ventilatory
strategies, such as lung recruitment strategy, can alter the diaphragm
level.
Moreover, among some special groups of patients, such as patients with
severe chest wall burn injury, the surface markers are not easily
identified.
Therefore, I use thoracic ultrasound before placing a chest tube, even
without a chest x ray film. Common diseases requiring a chest drainage,
including pneumothorax, hemothorax, empyema, and massive pleural effusion,
can be diagnosed by thoracic ultrasound. A quick look via thoracic
ultrasound can also prevent medical error, including placing a drain in
the wrong side or even in a different patient.
Kaye and Govier's case series of propofol sedation for DC cardioversion 1 provides a useful contribution to the relatively evidence-light area of Emergency Department (ED) sedation. I would, however, urge caution in their conclusion that propofol is a "safe" drug for the uses they describe.
Safety is obviously relative but, in the grand scheme of things, their series of 111 patients is small. The statistical "...
Kaye and Govier's case series of propofol sedation for DC cardioversion 1 provides a useful contribution to the relatively evidence-light area of Emergency Department (ED) sedation. I would, however, urge caution in their conclusion that propofol is a "safe" drug for the uses they describe.
Safety is obviously relative but, in the grand scheme of things, their series of 111 patients is small. The statistical "rule of three"2 suggests that, in a series with a zero incidence of a particular complication, the upper limit of the 95% confidence interval for the rate of that complication is approximately equal to one in n/3. Therefore, in the population they sampled, the rate of sentinel complications could as high as 1:37.
Although their paper adds useful further evidence of the utility of propofol for ED sedation, I would venture that few clinicians would consider a potential rate of CPR or death of 2.7% indicative of a "safe" sedation technique. Larger studies are needed, although I would agree wholeheartedly with their assertion that midazolam is far from the gold standard drug for these patients.
REFERENCES 1. Kaye P, Govier M. Procedural sedation with propofol for emergency DC cardioversion. Emerg. Med. J. 2014 31:904-908; doi:10.1136/emermed-2013-202742 2. Hanley JA, Lippman-Hand A. If nothing goes wrong, is everything alright?. JAMA 1983; 249 (13): 1743-5. doi:10.1001/jama.1983.03330370053031
As highlighted by Chou et al[1] it is becoming more evident that
extracorporeal membrane oxygenation (ECMO) during cardiopulmonary
resuscitation (CPR) is feasible and compares well against conventional
CPR. As technologies such as ECMO[2] and echocardiography (Echo),[3]
previously limited to intensive care units and cardiology suites, become
increasingly available in the Emergency Department (ED), it is important
that w...
As highlighted by Chou et al[1] it is becoming more evident that
extracorporeal membrane oxygenation (ECMO) during cardiopulmonary
resuscitation (CPR) is feasible and compares well against conventional
CPR. As technologies such as ECMO[2] and echocardiography (Echo),[3]
previously limited to intensive care units and cardiology suites, become
increasingly available in the Emergency Department (ED), it is important
that we fully utilize the information and support they can provide to
carefully select cardiac arrest patients for advanced ED resuscitation.
The percentage of patients who leave hospital alive following CPR
varies from 0% to 20% and has not significantly improved in the last 30
years.[4] The recently published CHEER trial (mechanical CPR, Hypothermia,
ECMO and Early Reperfusion), a single center, prospective, observational
study from Australia, assessed the CHEER protocol, developed for selected
patients with refractory in-hospital and out-of-hospital cardiac
arrest.[5] The protocol involved mechanical CPR, induction of intra-arrest
therapeutic hypothermia, early commencement of veno-arterial ECMO, and
early coronary angiography for patients with suspected coronary artery
occlusion. ECMO was established in 24 (92%) of 26 eligible patients, with
a median time from collapse until initiation of ECMO of 56 min. Return of
spontaneous circulation was achieved in 25 (96%) patients. Survival to
hospital discharge with full neurological recovery occurred in 14/26 (54%)
patients. Another study from the United States recently reported similar
survival rates; 13 of 24 (54%) patients survived to hospital discharge
with an ECMO based CPR protocol. Seven of these patients were discharged
without any neurological deficit.[6] While these early results show
promise for this form of advanced ED resuscitation, caution is required
before rolling out this technology for all cardiac arrest patients.
Can our health care systems afford the increased requirement of
intensive care bed-hours that such a policy would lead to? Can we select
which patients are most likely to benefit from ED-ECMO?
A meta-analysis of predictors of survival from out-of-hospital
cardiac arrest in 2010 found that survival to hospital discharge was more
likely among those witnessed by a bystander or emergency medical services
(EMS), those who received bystander CPR, were found in a shockable rhythm
(VF/VT), or achieved return of spontaneous circulation (ROSC).[4] A
further meta-analysis in 2012 looked at the of detection of cardiac
activity on echo to predict survival during cardiac arrest. Pooled data
showed that as a predictor of ROSC during cardiac arrest, echo had a
pooled sensitivity of 91.6%, and specificity was 80.0%;[7] promising, but
not independently predictive of survival.
Protocols including ED-ECMO are feasible and may be associated with a
relatively high survival rate. The introduction of such protocols to
emergency medicine should be encouraged, but must involve careful patient
selection, optimizing survival benefit. This may involve bedside echo in
the ED, as well as other demographic and clinically derived predictors of
survival.
1. Chou T.-H. An observational study of extracorporeal CPR for in-
hospital cardiac arrest secondary to myocardial infarction. Emerg Med J
2014;31: 441-7.
2. Shinar Z, Bellezzo J, Paradis N, et al. Emergency department
initiation of cardiopulmonary bypass: a case report and review of the
literature. J Emerg Med. 2012;43(1):83-6.
3. Hayhurst C, Lebus C, Atkinson PR, et al. An evaluation of echo in
life support (ELS): is it feasible? What does it add? Emerg Med J. 2011
Feb;28(2):119-21.
4. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest
treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the
CHEER trial). Resuscitation 2014. DOI:
http://dx.doi.org/10.1016/j.resuscitation.2014.09.010.
5. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival
from out-of-hospital cardiac arrest: a systematic review and meta-
analysis. ?Circ Cardiovasc Qual Outcomes 2010;3:63-81.
6. Peigh G, Pitcher H, Cavarocchi N, Hirose H. Saving Life And Brain
With Extracorporeal Cardiopulmonary Resuscitation (E-Cpr) Chest.
2014;146(4_MeetingAbstracts):722A. doi:10.1378/chest.1990723.
7. Blyth L, Atkinson P, Gadd K, Lang E. Bedside Focused
Echocardiography as Predictor of Survival in Cardiac Arrest Patients: A
Systematic Review. Acad Emerg Med 2012;19: 1119-1126.
A number of comments have been made to me regarding this article
since it was published. I would like to take this opportunity to clarify
that the experiences described did not occur whilst working at North Tees
University Hospital. This is where I currently work as a higher trainee in
Emergency Medicine. I am keen that the contents of the correspondence
address do not overshadow the key message of the article.
A number of comments have been made to me regarding this article
since it was published. I would like to take this opportunity to clarify
that the experiences described did not occur whilst working at North Tees
University Hospital. This is where I currently work as a higher trainee in
Emergency Medicine. I am keen that the contents of the correspondence
address do not overshadow the key message of the article.
The authors state that current evidence supports the use of a
negative D-dimer to rule out a suspicion of pulmonary embolism (PE) in
pregnancy. They show in Table 2 5 relevant studies to support their
conclusion. However, the study of Damodaram was the only study that
included patients with a clinical suspicion of venous thromboembolism,
thus including pulmonary embolism. All other 4 studies included either
healthy preg...
The authors state that current evidence supports the use of a
negative D-dimer to rule out a suspicion of pulmonary embolism (PE) in
pregnancy. They show in Table 2 5 relevant studies to support their
conclusion. However, the study of Damodaram was the only study that
included patients with a clinical suspicion of venous thromboembolism,
thus including pulmonary embolism. All other 4 studies included either
healthy pregnant patients or patients with a clinical suspicion of deep
vein thrombosis (DVT). Evidence found in healthy patients cannot be
extrapolated to pregnant symptomatic patients. Performance of the D-dimer
test should be tested in pregnant patients with a clinical suspicion of PE
before any recommendation can be made. Since PE is still one of the
leading causes of maternal death, ruling out this diagnosis accurately is
imperative.
Furthermore, in non-pregnant patients, use of D-dimer test as a stand
-alone test is not supported. The authors state that the Wells score can
be a useful tool in calculating pretest probability, as its categories
remain relevant. However, this statement is not supported by evidence. The
title of this BET may be interpreted as if a D-dimer test can be used as a
stand-alone test. In non-pregnant patients with a high suspicion of PE
(Wells score >4 points), the presence of PE is found to be 10%, despite
a negative D-dimer (Wells, Thromb Haemost 2000). Therefore, the most
important conclusion should be that there's a lack of good-quality
evidence concerning the management of a clinical suspicion of PE in
pregnancy.
Now 11+ years since SARS, it would be interesting to repeat this
study post Ebola... Are staff any better
prepared for a highly contagious, fatal disease?
The "Sepsis Six" resuscitation bundle is now common in UK hospitals,
and endorsed by the College of Emergency Medicine, SIGN guidelines, and
the Royal College of Physicians.1-3 However, the evidence behind it
remains limited and must be re-evaluated as new data emerges - especially
since the results of the PRoCESS and ARiSE trials on Early Goal Directed
Therapy (EGDT) were published this year.4,5...
The "Sepsis Six" resuscitation bundle is now common in UK hospitals,
and endorsed by the College of Emergency Medicine, SIGN guidelines, and
the Royal College of Physicians.1-3 However, the evidence behind it
remains limited and must be re-evaluated as new data emerges - especially
since the results of the PRoCESS and ARiSE trials on Early Goal Directed
Therapy (EGDT) were published this year.4,5
The paper supporting Sepsis Six was originally published in 2010 in
this Journal, and remains (as far as we are aware) the only published
evidence on Sepsis Six.6 We believe this trial is internally flawed, and
unable to provide convincing evidence of the benefit of Sepsis Six.
We have two main criticisms of this sepsis 6 trial - firstly, it is
inconsistent. Given that two large randomised controlled trials this year
have shown EGDT to have negligible effect on mortality, it is hard to
interpret the results of this trial - which showed a relative risk
reduction of 91% (mortality dropped from 90.3% without EGDT to 7.5% with
it). Also, the subgroup of patients who were shocked shows internal
inconsistencies. The worst performing group - with a staggering 97.1%
mortality were the shocked patients who received Sepsis 6 - yet if they
received EGDT alone, their mortality was 8%. However, the combination of
Sepsis 6 and EGDT in shocked patients performed best of all - with a 4.7%
mortality!
It seems inconceivable that in septic shock Sepsis 6 would increase
mortality to 97.1% if performed alone, but reduce it to 4.7% if performed
in combination with EGDT (which we know from RCT data has a negligible
effect).
The only possible explanation is that of confounding effects -
younger, fitter people were receiving EGDT and Sepsis 6- who had a low
mortality rate and survived, and less fit people did not receive it This
leads to our second criticism - lack of co-variate analysis. Although the
authors comment on the difference in age between some of the cohorts, they
did not perform a multivariate logistic regression (or similar) that could
have included age, MEWS score, source of infection. Given the complexity
and difference between the subgroups, it is impossible to compare them
without covariate statistical analysis.
It is very hard to draw causality from observational trials (and the
authors do not try here), but given the significant problems with this
trial, we do not feel it can be interpreted as supporting evidence for
Sepsis 6 either.
Although we do not aim to be unnecessary critical of what may be seen
as 'common sense practice', we have three main concerns. Firstly, the
claim that sepsis 6 in unlikely to be harmful is not a sufficient basis
for it's continued use. 'Common sense' medicine has repeatedly been proven
to be harmful on numerous occasions. Secondly, emergency departments and
wards are busy and under huge time pressure, and protocols that might tie
up staff for an hour or more must be scrutinised. Thirdly, sepsis 6 is
likely to lead to the greater use of stat doses of antibiotics in any
febrile patient, given the impetus to administer them within the first
hour for any unconfirmed sepsis diagnosis. We do not know the long-term
impact of this on antibiotic resistance - which is rapidly increasing.
Sepsis 6 means well, but is unproven, and should be treated as such.
Fergus Hamilton
Bryony Lewis
1. SIGN. Care of deteriorating patients: Guideline 139. 2014.
Available at: http://www.sign.ac.uk/pdf/SIGN139.pdf. Accessed October 14,
2014.
2. RCP. Acute Care Toolkit 9: Sepsis.; 2014.
3. College of Emergency Medicine. Clinical Standards for Emergency
Departments. 2013. Available at: http://www.collemergencymed.ac.uk/Shop-
Floor/Clinical Standards. Accessed October 14, 2014.
4. The ARISE Investigators and the ANZICS Clinical Trials Group.
Goal-Directed Resuscitation for Patients with Early Septic Shock. N. Engl.
J. Med. 2014:141001063014008. doi:10.1056/NEJMoa1404380.
5. Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of
protocol-based care for early septic shock. N. Engl. J. Med.
2014;370(18):1683-93. doi:10.1056/NEJMoa1401602.
6. Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and
the severe sepsis resuscitation bundle: a prospective observational cohort
study. Emerg. Med. J. 2011;28(6):507-12. doi:10.1136/emj.2010.095067.
Sir
I find the methodology for this paper to contain a significant flaw in
that the triage criteria used to determine suitability for the GP unit
contain a requirement that the patient will need minimal additional
resources for them to be processed. It is hardly surprising therefore that
the post intervention analysis sees fewer additional resources
subsequently spent on this group with the associated savings.
Sir
I find the methodology for this paper to contain a significant flaw in
that the triage criteria used to determine suitability for the GP unit
contain a requirement that the patient will need minimal additional
resources for them to be processed. It is hardly surprising therefore that
the post intervention analysis sees fewer additional resources
subsequently spent on this group with the associated savings.
In addition, it is contradictory to say that under the cost data the
ED cost per patient went up due to "some shift in patient mix after
triage" but in the discussion to claim that it was unlikely that the cost
differences were explained by differences between the two populations.
Finally, the rise in patient numbers of around 60% in 5 years
represents a phenomenal failure to contain the overall cost of emergency
care provision, despite the quoted lower costs per patient for the GP
unit. The conclusion that such a model represents "dominance" is therefore
quite extraordinary.
Sincerely
Wright and colleagues1 discuss some interesting issues around blood
cultures and sepsis outcome measurement. We agree that evaluating and
tracking sepsis associated mortality over time is important. It would
facilitate assessment of the impact of changes in practice, both intended
effects of sepsis improvement interventions and unintended consequences of
other initiatives, e.g. restrictive antibiotic policies, as well a...
Wright and colleagues1 discuss some interesting issues around blood
cultures and sepsis outcome measurement. We agree that evaluating and
tracking sepsis associated mortality over time is important. It would
facilitate assessment of the impact of changes in practice, both intended
effects of sepsis improvement interventions and unintended consequences of
other initiatives, e.g. restrictive antibiotic policies, as well as
epidemiological changes in populations. An ideal outcome measure would be
"simple, objective, clinically meaningful, resistant to ascertainment
bias, and, ideally, suitable for automation using data routinely stored in
electronic health records"2. Unfortunately, there is no such perfect
measure to track sepsis associated mortality.
Analysis of recorded International Classification of Diseases, Tenth
Revision (ICD-10) codes is frequently utilised for tracking trends in
healthcare, including mortality3. At first, this seems appealing as ICD-
10 codes should be simple and clinically meaningful and are available from
routinely collected data. However, inconsistency in assignment of codes
and changes in coding patterns make this susceptible to ascertainment bias
thereby compromising the validity and reliability of applying this as a
standalone measure2. Where remuneration and penalisation in healthcare is
linked to coding, there is also potential for gaming and coding trends to
emerge which do not reflect a real change in the population2,3.
Additionally, due to the presence of a range of appropriate codes that
could be applied to patients with sepsis, analysis of coding is complex4.
Both primary and secondary discharge codes require interrogation and organ
-specific infection codes, such as community-acquired pneumonia (ICD- 10
code J18.9), do not indicate whether the patient had sepsis, thereby
reducing the sensitivity of this as a measure. All-cause mortality is
also utilised within the literature. It is simple, objective and
routinely collected, however, it lacks sensitivity to detect the impact of
improvement interventions in clinical practice.
We agree with Wright et al that blood cultures should only be drawn
where appropriate. As advocated as part of the Sepsis Six5, when patients
fulfil two or more Systemic Inflammatory Response Syndrome (SIRS) criteria
(see Box 1) and have a suspected or confirmed source of infection blood
cultures should be obtained7.
Box 1:
SIRS criteria6
SIRS present when two or more of the following measured:
* Temperature <36oC or >38oC
* Heart Rate >90 beats/min
* Respiratory Rate >20 breaths/min OR PaCO2 <4.3kPa
* White blood cell count <4000/?L or >12000/?L
One concern which we share with Wright et al is that blood cultures
are often taken from patients who do not meet SIRS criteria, as found in
an audit of patients with cellulitis presenting to an Acute Medical Unit8,
but this is not encouraged if the Sepsis Six is implemented correctly.
Such snapshot audits are limited to the clinical observations available at
the time of data collection and this is likely to result in an
underestimation of the prevalence of sepsis at any time during a hospital
admission among patients who have a blood culture taken. With the
exception of immunocompromised patients or those with suspected
endocarditis, blood cultures should only be taken from patients who have
two or more SIRS criteria otherwise there is potential to waste resources
and cause patient harm7.
Wright et al reported a rise in blood culture sampling within NHS
Forth Valley. This should not necessarily be interpreted as a negative
development. The Scottish Trauma Audit Group9 reported that 39% (n=251)
of patients fulfilling criteria for severe sepsis in the emergency
department had no blood cultures sampled during the first 48 hours
following presentation. From this baseline the number of blood cultures
being drawn should rise initially if the Sepsis Six is being implemented
reliably. Interestingly the beginning of NHS Forth Valley's rise in blood
culture sampling appears to pre-date the beginning of the Scottish Patient
Safety Programme (SPSP) national Sepsis Collaborative in January 2012.
This apparently crude rate may reflect an already increasing awareness of
sepsis but may also have been influenced by the increasing number of
inpatient discharges in NHS Forth Valley in the period 2010-201310.
Wright et al suggest that the measurement of mortality among patients
with a positive blood culture would be more useful than blood cultures
alone. However, the proportion of patients with a positive blood culture
is a small subset of the wider sepsis population with one cohort reporting
that only 21% of patients with sepsis had a bacteraemia11. Therefore, to
restrict the measurement of sepsis associated mortality to this population
would significantly underestimate the true incidence of sepsis.
Additionally, the presence of a positive blood culture has not been
demonstrated to be independently associated with higher mortality once
adjusted for age, sex and comorbidity11,12. These considerations limit
the clinical meaningfulness of this as a measure, and negate Wright et
al's concern about "treating culture-negative sepsis with broad spectrum
antibiotics". This concern is not consistent with the objective of the
Sepsis Six, which is to ensure that patients with clinical signs of sepsis
receive prompt, appropriate and timely antibiotic treatment.
The proxy outcome measure for the SPSP national Sepsis Collaborative
examines the thirty day mortality among adult inpatients in acute
hospitals who have had a blood culture sampled. Utilising the existing
Scottish Hospital Standardised Mortality Ratio (HSMR) model, the data will
be adjusted for changes in clinical activity and acuity of care. However,
even crudely adjusted (e.g. for age, sex and occupied bed days or
admissions) blood culture mortality is a superior outcome measure compared
to the other currently proposed options. We accept that it is not perfect,
and are undertaking further work to validate its scope and applicability,
including investigating combining blood culture sampling with other
routinely available data. Improving the selection of patients for blood
culture sampling, as discussed above, would improve the performance of
this measure. However, even as it stands, it is simple, relatively
objective, clinically meaningful and more resistant to ascertainment bias
than most other options, and is suitable for automation using data
routinely stored in electronic health records.
References
1. Wright DJ, Beckett DJ, Cooke B. Use of sepsis 6 raises some
interesting questions. Emerg Med J Published Online First: 01.09.2014
2. Rhee C, Gohil S, Klompas M. Regulatory Mandates for Sepsis Care -
Reasons for Caution. N Engl J Med 2014; 370: 1673-1676
3. Vaughan Sarrazin MS, Rosenthal GE. Finding Pure and Simple Truths
with Administrative Data. JAMA 2012; 307(13):1433-1435
4. MacPherson D, Griffiths C, Williams M, Baker A, Klodawski E,
Jacobson B, Donaldson L. Sepsis-associated mortality in England: an
analysis of multiple cause of death data from 2001-2010. BMJ 2013;
3(8)e002586
5. Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and the
severe sepsis resuscitation bundle: a prospective observational cohort
study. Emerg Med J 2011; 28:507-512
6. Jones GR, Lowes JA. The systematic inflammatory response syndrome
as a predictor of bacteremia and outcome from sepsis. Q J Med 1996; 89:7
7. Coburn B, Morris Am, Tomlinson G, Detsky AS. Does This Adult
Patient With Suspected Bacteremia require blood cultures? JAMA 2012;
308:5
8. Marwick C, Rae N, Irvine N, Davey P. Prospective study of severity
assessment and management of acute medical admissions with skin and soft
tissue infection. J Antimicrob Chemother 2012; 67:1016-9.
9. The Scottish Trauma Audit Group. Sepsis Management in Scotland.
2010.
11. Marwick CA, Guthrie B, Pringle JE. Identifying which septic
patients have increased mortality risk using severity scores: a cohort
study. BMC Anesthesiol 2014; 14:1
12. Phua J, Ngerng WJ, See KC, Tay CK, Kiong T, Lim HF, Chew MY, Yip
HS, Tan A, Khalizah J, Capistrano R, Lee KH, Mukhopadhyay A.
Characteristics and outcomes of culture-negative versus culture-positive
severe sepsis. Critical Care 2014; 17:R202
Santiago Romero-Brufau, MD1; Jeanne M. Huddleston, MD1,2
1Healthcare Systems Engineering Program, Mayo Clinic Robert D. and
Patricia E. Kern Center for the Science of Health Care Delivery,
Rochester, MN, USA
2Division of Hospital Internal Medicine, Department of Internal Medicine,
Mayo Clinic, Rochester, MN, USA
Correspondence to:
Santiago Romero-Brufau, MD, Mayo Clinic Robert D. and Patricia E. Kern
C...
Santiago Romero-Brufau, MD1; Jeanne M. Huddleston, MD1,2
1Healthcare Systems Engineering Program, Mayo Clinic Robert D. and
Patricia E. Kern Center for the Science of Health Care Delivery,
Rochester, MN, USA
2Division of Hospital Internal Medicine, Department of Internal Medicine,
Mayo Clinic, Rochester, MN, USA
Correspondence to:
Santiago Romero-Brufau, MD, Mayo Clinic Robert D. and Patricia E. Kern
Center for the Science of Health Care Delivery, 200 First Street SW,
Rochester, MN 55905; romerobrufau.santiago@mayo.edu
We have read with much interest the article by Corfield et al.
published in a recent issue of Emergency Medicine Journal.1 They describe
calculation of the National Early Warning Score (NEWS) in a cohort of
septic patients admitted to the Emergency Department (ED). Their results
look very promising at first sight, as they report a positive predictive
value of 27% and 72% sensitivity for the combined outcome of in-hospital
death or admission to the intensive care unit (ICU). With these results,
they argue that "Among patients who have sepsis, a single EWS of ?7 in the
ED indicates a 27% chance of requiring admission to the ICU within 48h
and/or death within 30 days. At this level, an argument can be made for
mandating senior ED clinical review for all these patients," and they also
argue for review by a critical care outreach team.
However, there are important limitations and observations to be made.
First, out of the 2,489 patients who fulfilled "sepsis" criteria prior to
leaving the ED, 486 (19.5%) were not included in the final cohort for
missing data, and the characteristics of these excluded patients are not
reported. This exclusion of a large number of patients could bias the
cohort, as it can be argued that more severe patients are more likely to
have a complete set of observations captured.
Second, and more importantly, their inclusion criteria included patients
who were hospitalized for more than 48 hours, yet they added in patients
who died, regardless of their length of stay. This, in turn, has two
important consequences: it means that, to be able to know that a patient
has a certain probability, one has to know that the patient will have a
length of stay of more than 2 days, which requires data from the future
that is obviously not available on admission. But, more importantly, this
decision artificially increases the baseline outcome rate in the study's
cohort. The final cohort used in the analysis has an overall mortality
rate of 15%, and a combined outcome rate of 18%. This means that a
patient, just for meeting the study's eligibility criteria, has a 15% risk
of dying during the hospitalization. In the light of this finding, the
increased risk for a patient that has a NEWS ?7 is only 1.4 above the
average patient in their cohort.
Even the group of patients with the lowest NEWS (0-4) has an 8% risk of
the combined outcome, and a 5% in-hospital mortality risk. It could be
argued that this, too, would merit an evaluation by a senior ED clinician,
regardless of their NEWS score.
References
1. Corfield AR, Lees F, Zealley I, et al. Utility of a single early
warning score in patients with sepsis in the emergency department. Emerg
Med J. Jun 2014;31(6):482-487.
I agree with the authors that using the guidelines may not avoid subdiaphragmatic viceral injuries. First, many underlying diseases could alter the thorax shape and the diaphragm position. Second, in patients using positive mechanical ventilation support, many different ventilatory strategies, such as lung recruitment strategy, can alter the diaphragm level. Moreover, among some special groups of patients, such as patie...
Safety is obviously relative but, in the grand scheme of things, their series of 111 patients is small. The statistical "...
As highlighted by Chou et al[1] it is becoming more evident that extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR) is feasible and compares well against conventional CPR. As technologies such as ECMO[2] and echocardiography (Echo),[3] previously limited to intensive care units and cardiology suites, become increasingly available in the Emergency Department (ED), it is important that w...
A number of comments have been made to me regarding this article since it was published. I would like to take this opportunity to clarify that the experiences described did not occur whilst working at North Tees University Hospital. This is where I currently work as a higher trainee in Emergency Medicine. I am keen that the contents of the correspondence address do not overshadow the key message of the article.
C...
The authors state that current evidence supports the use of a negative D-dimer to rule out a suspicion of pulmonary embolism (PE) in pregnancy. They show in Table 2 5 relevant studies to support their conclusion. However, the study of Damodaram was the only study that included patients with a clinical suspicion of venous thromboembolism, thus including pulmonary embolism. All other 4 studies included either healthy preg...
Now 11+ years since SARS, it would be interesting to repeat this study post Ebola... Are staff any better prepared for a highly contagious, fatal disease?
Conflict of Interest:
None declared
Dear Editor,
The "Sepsis Six" resuscitation bundle is now common in UK hospitals, and endorsed by the College of Emergency Medicine, SIGN guidelines, and the Royal College of Physicians.1-3 However, the evidence behind it remains limited and must be re-evaluated as new data emerges - especially since the results of the PRoCESS and ARiSE trials on Early Goal Directed Therapy (EGDT) were published this year.4,5...
Sir I find the methodology for this paper to contain a significant flaw in that the triage criteria used to determine suitability for the GP unit contain a requirement that the patient will need minimal additional resources for them to be processed. It is hardly surprising therefore that the post intervention analysis sees fewer additional resources subsequently spent on this group with the associated savings.
...
Wright and colleagues1 discuss some interesting issues around blood cultures and sepsis outcome measurement. We agree that evaluating and tracking sepsis associated mortality over time is important. It would facilitate assessment of the impact of changes in practice, both intended effects of sepsis improvement interventions and unintended consequences of other initiatives, e.g. restrictive antibiotic policies, as well a...
Santiago Romero-Brufau, MD1; Jeanne M. Huddleston, MD1,2
1Healthcare Systems Engineering Program, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA 2Division of Hospital Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
Correspondence to: Santiago Romero-Brufau, MD, Mayo Clinic Robert D. and Patricia E. Kern C...
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