Deborah J. Williams

Proactive rounding by the rapid response team reduces inpatient cardiac arrests

OBJECTIVE Rapid response teams (RRTs) are frequently employed to respond to deteriorating inpatients. Proactive rounding (PR) consists of the RRT nurse rounding through the inpatient wards identifying high risk patients and intervening preemptively. At our institution, PR began in July of 2007. Our objective was to determine the effect of PR by the RRT at our institution on non-ICU cardiac arrests, code deaths, RRT interventions, and transfers to a higher level of care. Also, to report ICU transfer survival and survival to discharge rates after the start of PR. DESIGN Retrospective review of a prospectively collected database. SETTING A tertiary, academic, level 1 trauma center with 696 beds and a rapid response system. PATIENTS 1253 Non-ICU cardiac arrests from 2005 through June of 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The total study period included 223,267 inpatient admissions (70,129 pre-PR and 153,138 post-PR) and 1,250,814 patient days (391,088 pre-PR and 859,726 post-PR). The quarterly code rate before PR was 66 and the code rate after the institution of PR was 30 (difference=36.8, 95% CI 25.6-48.0, p<.001). Quarterly code deaths decreased from 29 to 7 (difference=21.95, 95% CI 16.3-27.6, p<.001). This decrease in floor codes and code deaths was still present after adjusting for inpatient admission and inpatient days. Average quarterly RRT interventions increased from 141 in the pre-PR period to 690 in the post-PR period (difference=549, 95% CI 360-738, p<.001). Average quarterly transfers to HLC went up from 38 pre-PR to 164 post-PR (difference=126, 95% CI 79-172, p<.001). CONCLUSIONS The institution of proactive rounding at a tertiary care, academic, level 1 trauma center results in reduced floor codes and code deaths as well as increased RRT interventions and transfers to a higher level of care.

The relationship of intravenous fluid chloride content to kidney function in patients with severe sepsis or septic shock

BACKGROUND Previous studies suggest a relationship between chloride-rich intravenous fluids and acute kidney injury in critically ill patients. OBJECTIVES The aim of this study was to evaluate the relationship of intravenous fluid chloride content to kidney function in patients with severe sepsis or septic shock. METHODS A retrospective chart review was performed to determine (1) quantity and type of bolus intravenous fluids, (2) serum creatinine (Cr) at presentation and upon discharge, and (3) need for emergent hemodialysis (HD) or renal replacement therapy (RRT). Linear regression was used for continuous outcomes, and logistic regression was used for binary outcomes and results were controlled for initial Cr. The primary outcome was change in Cr from admission to discharge. Secondary outcomes were need for HD/RRT, length of stay (LOS), mortality, and organ dysfunction. RESULTS There were 95 patients included in the final analysis; 48% (46) of patients presented with acute kidney injury, 8% (8) required first-time HD or RRT, 61% (58) were culture positive, 55% (52) were in shock, and overall mortality was 20% (19). There was no significant relationship between quantity of chloride administered in the first 24 hours with change in Cr (β = -0.0001, t = -0.86, R(2) = 0.92, P = .39), need for HD or RRT (odds ratio [OR] = 0.999; 95% confidence interval [CI], 0.999-1.000; P = .77), LOS >14 days (OR = 1.000; 95% CI, 0.999-1.000; P = .68), mortality (OR = 0.999; 95% CI, 0.999-1.000; P = .88), or any type of organ dysfunction. CONCLUSION Chloride administered in the first 24 hours did not influence kidney function in this cohort with severe sepsis or septic shock.

End-tidal carbon dioxide as a goal of early sepsis therapy.

OBJECTIVE To determine the use of end-tidal carbon dioxide (etco2) as an end point of sepsis resuscitation. METHODS This was a prospective, observational, single-center cohort study of emergency department patients receiving treatment for severe sepsis with a quantitative resuscitation protocol. Three etco2 readings were taken during a 1-minute time frame at 0, 3, and 6 hours of treatment. Linear regression was used to characterize the association between etco2 and central venous oxygen saturation (SCVo2) and lactate and also to determine the relationship between their change. Analysis of variance was used to determine the relationship between etco2 and disposition. RESULTS Sixty-nine patients were included in our final analysis. For baseline values, linear regression failed to show a relationship between etco2 and SCVo2 (β = -0.04, t(70) = -0.53, P = .60) but showed a nearly significant relationship (β = -0.51, t(70) = -1.90, P = .06) with lactate. There was no significant relationship between etco2 and SCVo2 at 3 hours (β = 0.12, t(70) = 1.43, P = .16) or 6 hours (β = 0.05, t(64) = 0.82, P = .67). There was also no significant relationship between 6-hour change in etco2 and change in SCVo2 (β = 0.04, t(64) = 0.43, P = .67) or lactate (β = 0.04, t(59) = 0.52, P = .60) or disposition (F(4) = 0.78, P = .54). CONCLUSION End-tidal carbon dioxide is unlikely to be a useful clinical end point for sepsis resuscitation, although it may be useful as a triage tool in suspected sepsis because baseline values may reflect initial lactate.

End-tidal carbon dioxide and occult injury in trauma patients ☆: ETCO2 does not rule out severe injury

OBJECTIVE To determine if early measurement of end-tidal carbon dioxide (ETCO2) in nonintubated patients triaged to a level 1 trauma center has utility in ruling out severe injury. METHODS We performed a prospective cohort study of adult patients triaged to our urban, academic, level 1 trauma center. Included patients had ETCO2 measured within 30 minutes of arrival. Chart review was performed on enrolled patients to identify severe injury defined by: admission to an intensive care unit, need for an invasive procedure, blood product transfusion, acute blood loss anemia, and acute clinically significant finding on computed tomographic scan. RESULTS Of 170 patients enrolled, 115 met the outcome of no severe injury. Mean ETCO2 for patients without and with severe injury was 33.1 mm Hg (SD, 5.8) and 30.3 mm Hg (SD, 6.7), respectively. This difference reached statistical significance (P=.05), but did not demonstrate added clinical utility when combined with Glasgow Coma Scale, systolic blood pressure, and age in predicting the primary outcome (area under curve, 0.70 with ETCO2 vs area under curve, 0.68 without ETCO2, P=.5). Patients with ETCO2 ≤30 mm Hg were found to be older, more likely to require intensive care unit admission or emergency operative intervention, develop acute blood loss anemia, and have an acute finding on computed tomography than patients with a higher ETCO2. CONCLUSION End-tidal carbon dioxide cannot be used to rule out severe injury in patients meeting criteria for trauma center care. The ETCO2 ≤30 mm Hg may be associated with increased risk of traumatic severe injury.

Clinical Decision Aids or Clinician Gestalt? Hard to Know Which Is Better

Editor’s Note: Dr. Bob Wears was a brilliant clinician and scientist; a tireless and erudite editor for this journal; and awonderful supporter of the Annals of Emergency Medicine Journal Club. He coauthored this September issue with his colleague, Dr. Deborah Williams, prior to his unexpected death. The Journal Club editors pass along our condolences to Bob’s family and work family at the University of Florida. You are reading the 59th installment of Annals of Emergency Medicine Journal Club. This Journal Club refers to the article by Schriger et al published in this month’s edition of Annals. This bimonthly feature seeks to improve the critical appraisal skills of emergency physicians and other interested readers through a guided critique of actual Annals of Emergency Medicine articles. Each Journal Club will pose questions that encourage readers—be they clinicians, academics, residents, or medical students—to critically appraise the literature. During a 2to 3-year cycle, we plan to ask questions that cover themain topics in researchmethodology and critical appraisal of the literature. To do this, we will select articles that use a variety of study designs and analytic techniques. These may or may not be the most clinically important articles in a specific issue, but they are articles that serve the mission of covering the clinical epidemiology curriculum. Journal Club entries are published in 2 phases. In the first phase, a list of questions about the article is published in the issue in which the article appears. Questions are rated “novice” ( ), “intermediate” ( ), and “advanced” ( ) so that individuals planning a journal club can assign the right question to the right student. The answers to this journal club will be published in the February 2018 issue. US residency directors will have immediate access to the answers through the Council of Emergency Medicine Residency Directors Share Point Web site. International residency directors can gain access to the questions by e-mailing journalclub@acep.org. Thus, if a program conducts its journal club within 5 months of the publication of the questions, no one will have access to the published answers except the residency director. The purpose of delaying the publication of the answers is to promote discussion and critical review of the literature by residents and medical students and discourage regurgitation of the published answers. It is our hope that the Journal Club will broaden Annals of Emergency Medicine’s appeal to residents and medical students. We are interested in receiving feedback about this feature. Please e-mail journalclub@acep.org with your comments.