The New England Journal of Medicine published a review of a Swedish intervention to increase the rates of bystander initiated CPR. The intervention in this study was the use of cellular technology to dispatch CPR trained bystanders who were within 500m to the cardiac arrest calls received by EMS dispatch systems. There were 5989 CPR trained bystanders recruited. The rate of bystander CPR was 17% higher in the intervention group, considering that bystander CPR may almost double chances for survival this could translate to many lives saved. This technology is available through a mobile app created by PulsePoint. PulsePoint allows responders to register to provide CPR, as well as to register the location of AED's. This could be an excellent public health measure, I would encourage everyone check to see if the service is available in your area, and to sign up if it is.http://www.nejm.org/doi/full/10.1056/NEJMoa1406038
There was a new systematic review and meta-analysis of Rapid Response Systems (RRS) published in Critical Care this month that observed a reduction in mortality associated with RRS teams. In this study CINAHL, PubMed, EMBASE and the Cochrane Collaboration were searched using RRS team keywords. 29 articles published between 1990 and 2013 were included, representing 2,160,213 patients (1,107,492 in the intervention arm). 65.5% of studies had 24/7 physician RSS team staffing. 25 of the studies were single center (21 in academic centers). RRS activation rates averaged 16.3/1000 admissions (95%CI 9.0-23.7), 33% (95%CI 23-43%) of these patients were transferred to ICU, and 9.7% (95%CI 4.5-14.9%) had changes made to their code status (DNAR). This study observed a decrease in mortality (RR 0.87, 95 %CI 0.81-0.95, p<0.001), as well as cardiac arrest rates (RR 0.65, 95%CI 0.61-0.70, p<0.001), with no effect on ICU admission rates (RR 0.90, 95%CI 0.70-1.16 p=0.43).These findings are contrary to both a 2010 systematic review and meta-analysis by Chan et al., and a review by Sendroni et al., published in Critical Care this year (see weekly review #2). This review included an additional 13 articles not included in the 2010 review, and 12 not reviewed by Sendroni et al. However if you take the three reviews and compare them side by side this review includes just 4 studies that where not in either of the other reviews. Two of the four articles excluded cardiac arrest within the ICU, and two of which were before/after and one a time series with no control, and therefore of relatively poor methodological strength. It would appear that the difference in findings between this review and the two preceding reviews are either due to two studies, both of which somewhat weak methodology (before/after without control), exclusion of patents who had in-ICU cardiac arrest, or a difference in interpreting the statistics.
I would be hesitant to say that this review is the final word on RRS teams. Likely we will need a well designed longitudinal study to assess for the impact of RRS systems on overall mortality; as both the MERIT trial and Sandroni review have noted that the longer a RRS system is in place, the more effective they become. From a nursing perspective RRS teams are useful: they channel patients that need ICU care into the ICU, they address inappropriate code statuses preventing expensive resuscitations, and, as time passes they may very well prove to have mortality benefit in general.
http://www.ccforum.com/content/pdf/s13054-015-0973-y.pdf
In Richard Lehman's NEJM journal review this week he discusses the implications of increased surveillance in the UK for cognitive decline. The increased surveillance comes at the recommendations of the National Institute for Health and Care Excellence (NICE) to screen for cognitive decline. Unfortunately the most commonly used tool for screening is the Mini Mental Status Exam (MMSE). The MMSE unfortunately has a poor diagnostic power (Sensitivity 81%, Specificity 89%). While these numbers may seem not too bad at first glance once one needs to keep in mind that it's being used at a population level for screening. Lehman uses this observation to suggest that there are better tools for the job, indeed there are, and a new systematic review published in JAMA has more great info on the subject. Even more importantly and generally speaking however are the ramifications of not using a Bayesian approach in using screening tools. For example if we use the diagnostic performance measures provided by JAMA for the MMSE (Sensitivity 81%, Specificity 89%), and apply them to the NICE provided estimates for alzheimers rates of 4.9/1000 (about 0.5% for people over 65 years old in the UK). Assuming it's used in a non-selective manner for patients over 65 years old as a screening tool we will have 109 false for every 4 true positives. This disconnect between test sensitivity and actually likelihood ratios is nothing new, it's been covered by ScanCrit and emlitofnote, both of whom have great write ups and case studies they covered last year. Services such as the Likelihood Ratio Database, and Diagnostic Test Calculator (screenshot below) can help to make sense of the mess, but from a clinical perspective it's important to not use these tools inappropriately in the absence of clinical findings.
http://blogs.bmj.com/bmj/2015/06/15/richard-lehmans-journal-review-15-june-2015/
The BBC ran a story this week discussing older adult patients being "trapped" in the hospital acute care system. The story discusses a report from Age UK, showing that a large number of patients in the acute care system are not only waiting for long term care or assisted living beds; but also home care services, social work services,or even just assistive devices at home such as stair lifts. While this is not really news for anyone working in health care, what is new is the shift in language away from patient blaming language. This news piece, refreshingly, changes the lens from: discussing these patients as "bed blockers" who "aren't sick"; to one that examines the system itself, and the inappropriate mix of services that leave patients with no other choice than to use higher acuity, more expensive beds to meet their basic needs. As a nurse working in emergency I'm well aware of the fact that patients are inappropriately channeled into the acute care system: visiting the ED for sore throats because they don't have access to primary health care, or dropping off their elderly relatives because the burden of caring for them has become to great. It's frustrating and easy to blame the patient for no knowing better than to use acute care services. Unfortunately patients already know better, they're accessing care the only way the can. It's time for health care systems to stop blaming patients for using the wrong service; especially when we're not offering them the services they need.http://www.bbc.com/news/health-33154093
No comments:
Post a Comment