Skip to content

1

Austin Wu

July 17, 2017

A patient presents to the emergency department presenting with precordial chest discomfort, pain radiating to the jaw, dyspnea, and diaphoresis. These are some of the typical symptoms highly indicative of acute coronary syndrome (ACS) [i]. However, not all patients have “typical” symptoms. Prior studies have shown that certain demographic groups, specifically patients of older age, black or Asian race, and female gender are less likely to present with these typical symptoms despite later having the diagnosis of ACS [ii].  In addition, other factors have been associated with atypical presentations including older age, and the presence of comorbid conditions such as diabetes.

While there is a large literature on atypical presentations of ACS, the combination of demographic factors – specifically combinations of race and gender – has not been closely explored until now. A recent study by researchers Drs. Ahmed Allabban, Judd Hollander and Jesse Pines at the George Washington University School of Medicine and Thomas Jefferson University published in the Emergency Medicine Journal focused on the combination of race and gender, and how the intersection of these two factors correlate with presentation of 30-day ACS or other serious cardiopulmonary diagnoses [iii]. The four subgroups were analyzed: black males, white males, black females, and white females.

The study was a secondary analysis of data collected from a prospective, observational cohort study of ED patients presenting with chest pain, with timeframe spanning from 1999 to 2008. The entire dataset was more than 4000 patients, and the study was conducted at an inner city academic hospital. Inclusion criteria included 30 years of age or older, presentation of chest pain where an ECG was ordered, and provision of informed consent. Patients who had chest trauma within the past week, a measured temperature of 101°F, used home oxygen, had metastatic cancer or had symptoms of palpitation alone without chest pain were excluded from the study.

The study found that symptoms associated with a higher risk of ACS in white males were left arm radiation, chest pressure and tightness, and substernal chest pain. These are typical symptoms of ACS.  For black males, the symptom associated with a higher risk of ACS was diaphoresis. For black females, symptoms indicating higher risk of ACS included diaphoresis, palpitations, and left arm radiation, while symptoms indicating lower risk for ACS included pleuritic chest pain and left anterior chest pain. No symptoms were predictive of ACS for white females. For serious cardiopulmonary diagnoses, there were largely similar findings. Results are displayed in the figure below.

The data demonstrates that dividing patient populations by a combination of race and gender produces variably predictive symptoms of both ACS and other serious cardiopulmonary diagnoses. Thus, relying on a particular set of typical symptoms regardless of demographic representation may not be an optimal form of practice.

This study had several limitations, including being a single center study, using convenience sampling, and having variations in sample size for each subgroup. Further, while this study highlights differences in symptoms among race and gender subgroups, the question of what causes these differences remains an area to be explored. Preliminary explanations include hormonal, physiological, and sociocultural differences among each of these subgroups, though these have not been substantiated. The main takeaway is that physicians in the ED should keep these symptomatic differences between race and gender in mind when assessing a patient for chest pain.

[i] Ayman El-Menyar et al., “Atypical Presentation of Acute Coronary Syndrome: A Significant Independent Predictor of in-Hospital Mortality,” Journal of Cardiology 57, no. 2 (March 2011): 165–71, doi:10.1016/j.jjcc.2010.11.008.

[ii] H. Lee et al., “Typical and Atypical Symptoms of Myocardial Infarction among African-Americans, Whites, and Koreans,” Critical Care Nursing Clinics of North America 13, no. 4 (December 2001): 531–39.

[iii] Ahmed Allabban, Judd E. Hollander, and Jesse M. Pines, “Gender, Race and the Presentation of Acute Coronary Syndrome and Serious Cardiopulmonary Diagnoses in ED Patients with Chest Pain,” Emerg Med J, June 16, 2017, emermed-2016-206104, doi:10.1136/emermed-2016-206104.


Austin Wu is a medical student at the GW School of Medicine & Health Sciences

Caitlin Carter

July 13, 2017

Antimicrobial overuse is the most significant preventable cause of drug resistance in both hospital and community settings[i].

Antibiotic overuse occurs among practitioners in nearly 2/3 of cases.

Overuse contributes to the growth of antibiotic resistant pathogens and the spread of antibiotic resistant infections that lead to increased morbidity, mortality, and health care costs.

Antimicrobial stewardship has emerged as a solution to combat this dangerous and preventable threat to patient safety. Antimicrobial stewardship is a collection of policies, guidelines, surveillance, data transparency, education, and evaluation to optimize antibiotic-prescribing practices. These strategies can lead to better patient outcomes, a decrease in adverse events and infections, and an optimized use of resources.

Last year the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America released a set of evidenced-based guidelines on antimicrobial stewardship in clinical settings[ii]. These guidelines serve to improve and measure the appropriate use of antibiotics across dosing, duration of care, and route of administration. While these guidelines were developed by a panel of clinicians and investigators across various medical disciplines.

Emergency physicians have a unique vantage point to affect antimicrobial stewardship in inpatient and outpatient settings.

The initial choice of antibiotic in the Emergency Department (ED) has important downstream implications. ED clinicians routinely prescribe antimicrobials for patients with skin and soft-tissue infections, urinary tract infections, bloodstream infections, as well as upper and lower respiratory infections. Broad-spectrum antibiotics are sometimes overused in EDs and other ambulatory settings, and in observational studies have shown significant overprescribing for acute bronchitis and other conditions.

Antimicrobial stewardship in ED settings is particularly challenging due to the high rates of ED crowding, the rapid rate of patient turnover, the need for quick decisions without consultation, the shift-based scheduling format of providers, and higher staff turnover rates than in other clinical settings. In addition, there are provider-centered factors that impact stewardship. This includes a perceived lack of efficacy, concerns about resource availability and reimbursement, as well as perceived hindrance to operational efficiency. Providers are also concerned about medical liability and patient satisfaction, which has shown to be an important facet of antibiotic prescription in the ED.

Challenges to antimicrobial stewardship in ED settings are unique, numerous, and require strategies that consider the ED as well as other key stakeholders. ED specific guidelines are still needed that consider clinical decision support systems, post prescription review, rapid diagnostics, duration of therapy, dosage, and ED antibiogram development.

To learn more about antimicrobial stewardship and implications for emergency medicine please see Dr. Larissa May’s podcast and webinar available only through Urgent Matters. For an overview of antibiotic use in pneumonia, please see Dr. Jesse Pines’ webinar on the burden of community-acquired pneumonia and current issues in emergency care.

These programs were funded through an educational grant from Cempra, Inc. (CEMP) who had no role in the content.

[i] May, L., Cosgrove, S., et al. “A Call to Action for Antimicrobial Stewardship in the Emergency Department: Approaches and Strategies.” Annals of Emergency Medicine (2013).

[ii] Barlam, T.F., Cosgrove, S.E., et al. “Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.” Clinical Infectious Diseases (2016).


Caitlin Carter, MPH is a research associate and manager for the Urgent Matters program

 

Sonya Chistov

July 6, 2017

A young patient presents to the emergency department (ED) with altered mental status. According to EMS providers, she had ingested an unknown substance, and now was combative, screaming and flailing uncontrollably. Her point-of-care glucose level is normal. She is immediately restrained and sedated, placed in an isolated room and labeled “just another intoxication”. After hours of sleeping, her mental status is not normalizing.  Labs are finally ordered after carefully looking through previous visits and discovering no previous psychiatric history. The patient is found to have an elevated WBC count, is discovered to be febrile and tachycardic. Therefore, what was initially considered a behavioral health issue is actually a medical one that requires immediate care.

Considering the numbers of cases that present similarly to this one, is there a common protocol to distinguish medical from psychiatric emergencies?

Following the closure of institutional psychiatric facilities in the 1980s, EDs are the main location for treatment of patients with a variety of psychiatric complaints [1]. For many behavioral health visits, emergency medicine physicians are commonly tasked with evaluating patients and “medically clearing” them before evaluation by psychiatrists. Medical clearance differs in definition regionally, but often, a set of protocol orders is required before the patient can be further evaluated for evaluation by psychiatrists and potential admission to a psychiatric unit versus a medical unit [2,3]. There has been ongoing debate regarding the necessity of these tests for many patients, because they are often negative and often could potentially be avoided based on clinical grounds.

Each patient in the ED is provided with a physical exam and medical history. If the patient is alert and oriented, expressing only psychiatric complaints, what orders are then deemed necessary for medical clearance?  In many cases, ED physicians will order a basic metabolic panel (BMP), complete blood count (CBC), other functional “psych” lab tests, electrocardiogram (ECG), and a urine drug analysis, as well as an assessment of common overdoses particularly salicylates, acetaminophen, and alcohol. Even with positive urine analysis for drug use, the ED often does not provide further interventions except for time and space to metabolize the ingested agent. [3]

A recent article by Brown et al, in Annals of Emergency Medicine, reviewed numerous studies regarding protocolized psychiatric orders and determined that these tests often had low diagnostic yield, and rarely affected original decisions in disposition. However, the article also noted that psychiatric patients tend to have higher rates of co-morbidities and a shorter general life span, so generic laboratory testing sometimes leads to positive results that may or may not be directly relevant to the ED care. Patients also spend long periods of time in the ED before evaluation, until the decision for admission is made, and until they receive a hospital bed. [4,5,6] Those in favor of the standardized testing work closely within the medical model. These people suggest that underlying illness can influence psychiatric complaints, and these tests can determine or eliminate a direct or organic medical cause. Also, due to overcrowding on inpatient psychiatric units, the use of these tests can weed cases that may be more appropriate for “medicine” cases, saving room for true psychiatric emergencies. [4,5,6]

The lack of consensus regarding all aspects of this issue is astounding, but ultimately it comes down to two things: time and money. If patients complaining of new onset psychiatric complaints, with no other previous medical history, are evaluated the same as patients with a history of psychiatric complaints, substance abuse, or extensive co-morbidities, is it necessary to be “treated” in the ED? In my humble opinion, our healthcare system should develop a standardized protocol, which can compromise between both sides of this argument. If a patient presents with psychiatric symptoms, they should be examined as any other patient with a routine physical exam and obtaining a detailed medical history. If the patient has stable vitals, normal physical exam, no substance abuse (altered mental status) and no other complaints- the complaint could potentially be evaluated directly by psychiatrists or within a psychiatric-focused ED, as many hospitals have this already. For patients deemed a higher risk, such as elderly patients, patients with new onset psychiatric symptoms and patients with altered mental status, testing should be determined based on each patient’s presentation and medical necessity, and by the treating ED physician.

References:

[1] Larkin GL, Claassen CA, Emond JA, Pelletier AJ, Camargo CA. Trends in US emergency department visits for mental health conditions, 1992 to 2001. Psychiatric services. 2005 Jun;56(6):671-7.

[2] Brown, MD. et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Annals of Emergency Medicine. 2017, Feb; 69(4): 480-98

[3] Turner JE, Zun LS. An Evidence-Based Approach to Medical Clearance of Psychiatric Patients in the Emergency Department. Current Emergency and Hospital Medicine Reports. 2015 Dec 1;3(4):176-82.

[4] Tucci V, Siever K, Matorin A, Moukaddam N. Down the rabbit hole: emergency department medical clearance of patients with psychiatric or behavioral emergencies. Emergency medicine clinics of North America. 2015 Nov 30;33(4):721-37.

[5] Anderson EL, Nordstrom K, Wilson MP, et al. American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines. Western Journal of Emergency Medicine. 2017;18(2):235-242.

[6] Zun L. Care of psychiatric patients: The challenge to emergency physicians. Western journal of emergency medicine. 2016 Mar;17(2):173.


Sonya Chistov is an ED Technician at The George Washington University Hospital