Steffen Popp

High-sensitivity troponin assays in the evaluation of patients with acute chest pain in the emergency department.

Abstract Evaluating patients with acute chest pain presenting to the emergency department remains an ongoing challenge. The spectrum of etiologies in acute chest pain ranges from minor disease entities to life-threatening diseases, such as pulmonary embolism, acute aortic dissection or acute myocardial infarction (MI). The diagnosis of acute MI is usually made integrating the triad of patient history and clinical presentation, readings of 12-lead ECG and measurement of cardiac troponins (cTn). Introduction of high-sensitivity cTn assays substantially increases sensitivity to identify patients with acute MI even at the time of presentation to the emergency department at the cost of specificity. However, the proportion of patients presenting with cTn positive, non-vascular cardiac chest pain triples with the implementation of new sensitive cTn assays increasing the difficulty for the emergency physician to identify those patients who are at need for invasive diagnostics. The main objectives of this mini-review are 1) to discuss elements of disposition decision made by the emergency physician for the evaluation of chest pain patients, 2) to summarize recent advances in assay technology and relate these findings into the clinical context, and 3) to discuss possible consequences for the clinical work and suggest an algorithm for the clinical evaluation of chest pain patients in the emergency department.

Patients With Syncope in a German Emergency Department: Description of Patients and Processes

BACKGROUND We studied the characteristics and resource utilization of patients with syncope in a German emergency department (ED). METHODS We carried out a single-center retrospective analysis of patients with syncope who presented to the ED of the Klinikum Nürnberg (a municipal hospital in Nuremberg, Germany). RESULTS Among the 28 477 patients who presented to the ED from 15 May 2009 to 30 September 2009, 440 (1.5%) presented with syncope. Their mean age was 62 years (standard deviation, 20 years); 50.4% were women, 43.4% were over age 70, 11.8% had cardiogenic and 4.8% neurological syncope, and 18.2% had more than two comorbid conditions. 20.7% were discharged after evaluation in the ED, 14.1% were brielfly hospitalized in the EDs clinical observation unit, and 56.6% were admitted to one of the hospitals specialty wards. 8.6% left the ED against medical advice. All of the syncope patients were evaluated by history-taking, physical examination, and 12-lead electrocardiogragraphy (ECG); ECG revealed abnormal findings in 36.4% of patients. Nearly all patients also underwent laboratory testing, which revealed hyponatremia (a serum sodium concentration under 130 mmol/L) in 5.9% and a serum creatinine level above 2 mg/dL in 5.3%. Many underwent technology-intensive tests such as cranial computed tomography (129 patients), but these tests only rarely yielded abnormal findings (3.1%). 27% of the syncope patients underwent Doppler ultrasonography of the vessels supplying the brain, with abnormal findings in 6.7% of cases. (Orthostatic testing was performed in 14.5% of the patients and was positive in 26.6%.) CONCLUSION Many patients presenting with syncope to a German ED are elderly, and multiple comorbidities are common. Technology-intensive testing in patients with syncope has a low diagnostic yield and consumes resources. The introduction of standards for the evaluation of syncope in the ED would be helpful.

Reduction of mortality in community-acquired pneumonia after implementing standardized care bundles in the emergency department.

Objectives Community-acquired pneumonia (CAP) is associated with high in-hospital mortality. Standardization of diagnostics and adherence to sepsis bundles in the emergency department (ED) are associated with reduced mortality in patients with sepsis. We examined whether introduction of standardized care bundles and checklists in the ED is associated with reduced mortality in patients hospitalized for CAP. Methods We retrospectively analyzed performance indicators of 2819 consecutive patients with CAP admitted to the Nuremberg Hospital, Germany, from 2008 to 2009. At the turn of the year, CAP care bundles were implemented including interprofessional education, check lists, and institutionalized feedback. Primary endpoint was in-hospital mortality of CAP patients. The secondary endpoint was mortality in the subgroups of CRB-65 risk classes (C, mental confusion; R respiratory rate≥30/min; B systolic blood pressure<90 mmHg; 65, age≥65 years). Results After implementation of CAP care bundles in the ED, in-hospital mortality of affected patients was significantly lower in 2009 compared with 2008 (11.3 vs. 14.3%; P=0.02). Lower mortality was observed in CRB-65 risk classes 2 (n=2142; 11.9 vs. 15.4%, P=0.02) and 3 (n=119; 36.6 vs. 47.9%, P=0.21). Lower in-hospital mortality was also observed in patients between 18 and 79 years (7.2 vs. 10.7%; P=0.02). Mortality in the 80 years and older group was not significantly different after implementation of the CAP care bundle. Antimicrobial therapy was started earlier in the CAP care bundle group (72.8 vs. 82.7% within the first 4 h; P=0.0001), and length of stay in the hospital was significantly reduced from 9 to 8 days (P=0.02). Conclusion This study demonstrated that implementation of standardized CAP care bundles in the ED is associated with a 21% relative risk reduction of in-hospital mortality. Standardization of diagnostic and therapeutic processes in the ED improves outcome of patients hospitalized for CAP.

The Prevalence and Prognostic Significance of Near Syncope and Syncope: A prospective study of 395 cases in an emergency department (the SPEED Study)

BACKGROUND The prognostic significance of near-syncope has not yet been adequately characterized. METHOD We collected prospective data on a consecutive series of patients seen in an emergency department with syncope (brief loss of consciousness, usually with loss of muscle tone) or near-syncope (a feeling that syncope is about to occur, but without actual loss of consciousness or muscle tone). We report on the prevalence, etiology, and prognosis of such events (the SPEED study). Patients were followed up at 30 days and at 6 months after the event. RESULTS From 17 July to 31 October 2011, 395 patients were seen in the emergency department for a chief complaint of syncope or near-syncope (3% of all emergency patients). Their median age was 70 years, and 55% were men. 62% had experienced syncope, and 38% near-syncope. The patients with near-syncope were younger than those with syncope ( 63 vs. 72 years, p < 0.014) and were also more commonly male (63% vs. 49%, p = 0.006). The two patient groups did not differ significantly with respect to their measured laboratory values and vital parameters or their accompanying medical conditions. Hospitalizations were more common for syncope than for near-syncope (86% vs. 70%, p < 0.001). Etiologies were similarly distributed in the two patient groups, with the main ones being reflex syncope, orthostatic syncope, cardiac syncope, and syncope of uncertain origin. In all, 123 of 379 patients (32%) had further undesired events within 30 days of the event. Multivariable logistic regression revealed that age, heart rate, and renal dysfunction were independent predictors of undesired events, while the type of syncope was not. CONCLUSION Patients with near-syncope do not differ to any large extent from patients with syncope with respect to the features studied. The diagnostic evaluation should be similar for patients in the two groups.

Diagnostic and Prognostic Value of High-sensitivity Cardiac Troponin T in Patients with Syncope

OBJECTIVE We examined the diagnostic and predictive value of high-sensitivity cardiac troponin T (cTnThs) in patients with syncope. METHODS We performed an analysis of consecutive patients with syncope presenting to the emergency department. The primary end point was the accuracy to diagnose a cardiac syncope. In addition, the study explored the prognostic relevance of cTnThs in patients with cardiac and noncardiac syncope. RESULTS A total of 360 patients were enrolled (median age, 70.5 years; male, 55.8%; 23.9% aged >80 years). Cardiac syncope was present in 22% of patients, reflex syncope was present in 40% of patients, syncope due to orthostatic hypotension was present in 20% of patients, and unexplained syncope was present in 17.5% of patients. A total of 148 patients (41%) had cTnThs levels above the 99% confidence interval (CI) (cutoff point). The diagnostic accuracy for cTnThs levels to determine the diagnosis of cardiac syncope was quantified by the area under the curve (0.77; CI, 0.72-0.83; P < .001). A comparable area under the curve (0.78; CI, 0.73-0.83; P < .001) was obtained for the predictive value of cTnThs levels within 30 days: Patients with increased cTnThs levels had a 52% likelihood for adverse events, patients with cTnThs levels below the cutoff point had a low risk (negative predictive value, 83.5%). Increased cTnThs levels indicate adverse prognosis in patients with noncardiac causes of syncope, but not in patients with cardiac syncope being a risk factor for adverse outcome by itself. CONCLUSIONS Patients with syncope presenting to the emergency department have a high proportion of life-threatening conditions. cTnThs levels show a limited diagnostic and predictive accuracy for the identification of patients with syncope at high risk.

Gedanken zur Fehler- und Sicherheitskultur in deutschen Notaufnahmen

ZusammenfassungEine Patientin wird bei vasovagaler Synkope mit Sturz auf den Kopf in eine chirurgische Notaufnahme eingewiesen und nach kurzer Abklärung zunächst in die ambulante Weiterbehandlung entlassen. Wenige Tage später verstirbt sie auf der Intensivstation an einem Toxic-Shock-Syndrom. Nach einer systematischen Literaturrecherche wird an diesem Fallbeispiel die Thematik „medizinischer Fehler“ im Kontext der deutschen Notaufnahmestrukturen diskutiert, die momentan meist dezentral organisiert sind. Nachfolgend werden die theoretischen Grundlagen von Fehlern im Allgemeinen sowohl anhand der Arbeiten von James Reason als auch in Bezug auf das Fallbeispiel dargestellt. Wir plädieren für einen Wandel hin zu einer systematischen Fehlerkultur, in der nicht allein die persönliche Verantwortlichkeit des Handelnden am Ende der Handlungskette im Vordergrund steht, sondern Fehler in der Notaufnahme durch systematische Aufarbeitung der zugrundeliegenden Mechanismen vermieden werden. Dabei wäre es nützlich, wenn Maßnahmenbündel aus verschiedenen qualitätsrelevanten Bereichen (Qualitätsmessung, Prozessstruktur, Arbeitskultur) in der Notaufnahme eingeführt würden. Abschließend werden ausgewählte Elemente dieser Maßnahmen in der Arbeit diskutiert.AbstractA female patient with vasovagal syncope was admitted to a trauma unit. After short evaluation, the patient was discharged to outpatient care and was readmitted to the ICU a few days later. Shortly after ICU admission, she died due to toxic shock syndrome. This example in the context of a review of the literature is used to illustrate the importance of medical errors in German emergency departments, which are currently not managed in a central unit. Subsequently, with the help of James Reason’s theories on error, this paper describes the theoretic background of errors and correlates them to the case example. We plead for a change to a systematic safety culture in which errors are not seen as individual failures but as endpoints of subsequent events where systematic workup of underlying mechanisms can improve patient safety. We suggest the implementation of“intervention bundles” that contain elements of different quality categories: measuring quality, structuring processes and improving work culture. Finally, this work discusses examples of these elements with their advantages and disadvantages and the aim to transform emergency medical care in Germany to a systematic error and safety culture.