Clinical Education in the 21st Century

Here’s a Prezi I gave to a group of St. John Ambulance volunteers about the future of clinical education.  A fairly lighthearted look at the use of social media and simulation in clinical education.  Enjoy.
Updated – here’s the video.

Beta test

I love it when a controversy pops up in the intensive care literature.  Especially when it doesn’t involve steroids.  My favourite paper of last year was definitely FEAST because I think it took a topic that we thought we knew so much about and turned it on it’s head.  There’s a few months left in 2012 but a big contender for my favourite paper of this year would have to be this little gem from Macchia et al in Italy.  They performed a large retrospective analysis of 9465 patients admitted to ICU with sepsis in 22 regions of Italy over a 5 year period between 2003 and 2008.  They found that 1061 patients had been taking beta blockers before their ICU admission and 8404 patients had not.

Surprisingly, despite their overall poorer baseline status, those who were taking beta blockers prior to ICU admission had a 28 day mortality rate 20% less than those who weren’t!  Overall 28 day mortality was 17.7% in the beta-blocker group and 22.1% in the control group.  So an absolute risk reduction of 4.4% and a relative risk reduction of 19%.  This gives an NNT of 23 patients to save one life with beta blockers.

Now obviously this was a retrospective analysis with all of the inherent risks and biases, but there is a plausible physiological mechanism underlying the observed effect.  Animal data has shown for some years that administering beta blockers to rats and pigs with septic shock induced myocardial dysfunction results in improved survival and, somewhat counter-intuitively seems to reduce myocardial dysfunction.  There are various theories as to why this may be, but the one that seems predominant is that there is an adrenergic storm associated with septic shock, resulting in increased cardiac workload at a time of limited oxygen supply.  This results in the myocardial dysfunction seen in 60% of patients with septic shock.  It is thought that beta blockers prevent this catecholamine storm from having a detrimental effect on the heart.

It’s food for thought anyway, and there’s a small trial underway at the moment that’s randomising patients with septic shock to either esmolol or placebo.  But they’re only recruiting 100 patients and many more will be required to give us the answer.  This sounds like a job for ANZICS….

1. Crit Care Med. 2012 Oct;40(10):2768-72.

Previous prescription of β-blockers is associated with reduced mortality among
patients hospitalized in intensive care units for sepsis*.

Macchia A, Romero M, Comignani PD, Mariani J, D'Ettorre A, Prini N, Santopinto M,
Tognoni G.

From the Laboratory of Pharmacoepidemiology (MA, RM, D'EA, TG), Consorzio Mario
Negri Sud, Santa Maria Imbaro (CH), Italy; Fundación GESICA (MA, MJ), Buenos
Aires, Argentina; and Critical Care Unit (MA, CPD, PN, SM), Hospital Alemán,
Buenos Aires, Argentina.

OBJECTIVES: : Results from basic science and narrative reviews suggest a
potential role of β-blockers in patients with sepsis. Although the hypothesis is 
physiologically appealing, it could be seen as clinically counterintuitive. We
sought to assess whether patients previously prescribed chronic β-blocker therapy
had a different mortality rate than those who did not receive treatment.
SETTING: : Record linkage of administrative databases of Italian patients
hospitalized for sepsis during years 2003-2008 were identified and followed up
for all-cause mortality at 28 days.
INTERVENTIONS: : None.
MEASUREMENTS AND MAIN RESULTS: : We identified 9,465 patients aged ≥40 yrs who
were hospitalized in critical care units for sepsis. Of these, 1,061 patients
were on chronic prescription with β-blockers and 8404 were not previously
treated. Despite a higher risk profile, patients previously prescribed with
β-blockers had lower mortality at 28 days (188/1061 [17.7%]) than those
previously untreated (1857/8404 [22.1%]) (odds ratio 0.78; 95% confidence
interval 0.66-0.93; p = .005 for unadjusted analysis, and odds ratio 0.81; 95%
confidence interval 0.68-0.97; p = .025 for adjusted analyses). Sensitivity and
pair-matched results confirm the primary findings.
CONCLUSIONS: : As far as we are aware, this pharmacoepidemiologic assessment is
the largest to examine the potential association of previous β-blocker
prescription and mortality in patients with sepsis. Chronic prescription of
β-blockers may confer a survival advantage to patients who subsequently develop
sepsis with organ dysfunction and who are admitted to an intensive care unit.
Prospective randomized clinical trials should formally test this hypothesis.

PMID: 22824934  [PubMed - in process]

Behind the Mask

Here’s an article I wrote last year for the popular EMS journal/magazine JEMS.

http://www.jems.com/behind-the-mask
Or, if you’d prefer a downloadable online pdf format…

http://jems.epubxp.com/i/34750

I got into intensive care for the resuscitation and the trauma.  I stayed for the arguments and the controversy ;)  And yes I really was taught as a youngster that oxygen was an analgesic.

EEG is better then SSEP for prognostication at 24 hours in patients cooled post cardiac arrest

Interesting study from the Netherlands in this months CCM.  Patients treated with therapeutic hypothermia for cardiac arrest (regardless of etiology or location) had continuous electroencephalogram (EEG) and daily somatosensory evoked potentials (SSEP) to see if EEG shows any benefit compared with SSEP with regards to early prognostication.  It has become difficult to clinically prognosticate as it seems likely that hypothermia delays the time to neurological recovery.  A method that reliable allowed early prognostication would allow us to provide better care to patients and families by appropriately palliating those with no chance of meaningful neurological recovery and also by carrying on with aggressive treatment for those with a good chance of recovery.
Both isoelectric EEG and absent SSEP had sensitivity of 100% for poor outcome at 24 hours.  Specificity of SSEP for 24%, while specificity of EEG was 68%.  So it appears that EEG can identify more non-survivors earlier.  Important notes of caution were that this was a relatively small (60 patient), single center study.  Also, the study wasn’t completely blinded.  Clinicians were allowed access to both EEG and SSEP data. The authors state that access was needed to EEG data so that epileptiform discharges could be treated, but obviously a flat EEG at 24 hours could have become a self-fulfilling prophecy.

Anyway, here’s the study

http://www.ncbi.nlm.nih.gov/pubmed?term=22824933

1. Crit Care Med. 2012 Oct;40(10):2867-75.

Continuous electroencephalography monitoring for early prediction of neurological
outcome in postanoxic patients after cardiac arrest: A prospective cohort study*.

Cloostermans MC, van Meulen FB, Eertman CJ, Hom HW, van Putten MJ.

From the Chair of Clinical Neurophysiology (MCC, FBvM, MJAMvP), MIRA institute
for Biomedical Engineering and Technical Medicine, University of Twente,
Enschede, The Netherlands; Department of Clinical Neurophysiology and Neurology
(MCC, CJE, MJAMvP), and Department of Intensive Care Medicine (HWH), Medisch
Spectrum Twente, Enschede, The Netherlands.

OBJECTIVE: : To evaluate the value of continuous electroencephalography in early 
prognostication in patients treated with hypothermia after cardiac arrest.
DESIGN: : Prospective cohort study.
SETTING: : Medical intensive care unit.
PATIENTS: : Sixty patients admitted to the intensive care unit for therapeutic
hypothermia after cardiac arrest.
INTERVENTION: : None.
MEASUREMENTS AND MAIN RESULTS: : In all patients, continuous electroencephalogram
and daily somatosensory evoked potentials were recorded during the first 5 days
of admission or until intensive care unit discharge. Neurological outcomes were
based on each patient's best achieved Cerebral Performance Category score within 
6 months. Twenty-seven of 56 patients (48%) achieved good neurological outcome
(Cerebral Performance Category score 1-2).At 12 hrs after resuscitation, 43% of
the patients with good neurological outcome showed continuous, diffuse slow
electroencephalogram rhythms, whereas this was never observed in patients with
poor outcome.The sensitivity for predicting poor neurological outcome of
low-voltage and isoelectric electroencephalogram patterns 24 hrs after
resuscitation was 40% (95% confidence interval 19%-64%) with a 100% specificity
(confidence interval 86%-100%), whereas the sensitivity and specificity of absent
somatosensory evoked potential responses during the first 24 hrs were 24%
(confidence interval 10%-44%) and 100% (confidence interval: 87%-100%),
respectively. The negative predictive value for poor outcome of low-voltage and
isoelectric electroencephalogram patterns was 68% (confidence interval 50%-81%)
compared to 55% (confidence interval 40%-60%) for bilateral somatosensory evoked 
potential absence, both with a positive predictive value of 100% (confidence
interval 63%-100% and 59%-100% respectively). Burst-suppression patterns after 24
hrs were also associated with poor neurological outcome, but not inevitably so.
CONCLUSIONS: : In patients treated with hypothermia, electroencephalogram
monitoring during the first 24 hrs after resuscitation can contribute to the
prediction of both good and poor neurological outcome. Continuous patterns within
12 hrs predicted good outcome. Isoelectric or low-voltage electroencephalograms
after 24 hrs predicted poor outcome with a sensitivity almost two times larger
than bilateral absent somatosensory evoked potential responses.

PMID: 22824933  [PubMed - in process]

Intensivists achieve better outcomes for less money. Surprise!

I can’t even begin to fathom the health system in the USA. But one thing I do know is that in many hospitals critically ill patients in ICU aren’t looked after by intensivists. So-called “open-unit ICU” is the norm where all specialists can admit their patients to ICU and manage them once there.

This interesting little before and after analysis by Parikh et al in this month’s edition of Critical Care Medicine shows that the introduction of specialist intensivists providing care for patients in a 12 bed mixed ICU in a community hospital is associated with some pretty impressive outcomes. What struck me most was that those patients who weren’t looked after by an intensivist were 6 times more likely to get ventilator associated pneumonia and 8 times more likely to get Central Line Associated Bloodstream Infection (CLABSI). What were the non-intensivists doing? Spitting on their hands before performing procedures?

Also of note was that those cared for by intensivists got out of ICU a day sooner and the hospital ended up with a net saving at the end of the year of about $800,000. This is amusing because apparently one of the most commonly cited reasons for not hiring intensivists is that they cost too much! I suspect the actual reason for intensivists not being ubiquitous in the US is simply territorial behaviour by other specialists.

Unfortunately the study didn’t show that intensivists saved lives, but it wasn’t powered to do so and previous studies have already shown that care provided by intensivists decreases both ICU and hospital mortality by 1/3.

Anyway, check it out for yourself if this kind of stuff floats your boat.
http://www.ncbi.nlm.nih.gov/pubmed/22824939

Crit Care Med. 2012 Jul 20. [Epub ahead of print]

Quality improvement and cost savings after implementation of the Leapfrog intensive care unit physician staffing standard at a community teaching hospital.

Parikh A, Huang SA, Murthy P, Dombrovskiy V, Nolledo M, Lefton R, Scardella AT.

From the UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ (AP, SAH, PM, VD, MN, ATS); and University Medical Center at Princeton, Princeton, NJ (MN, RL).

Abstract

BACKGROUND:
Prior studies have shown that implementation of the Leapfrog intensive care unit physician staffing standard of dedicated intensivists providing 24-hr intensive care unit coverage reduces length of stay and in-hospital mortality. A theoretical model of the cost-effectiveness of intensive care unit physician staffing patterns has also been published, but no study has examined the actual cost vs. cost savings of such a program.

OBJECTIVE:
To determine whether improved outcomes in specific quality measures would result in an overall cost savings in patient care

DESIGN:
Retrospective, 1 yr before-after cohort study

SETTING:
A 15-bed mixed medical-surgical community intensive care unit

PATIENTS:
A total of 2,181 patients: 1,113 patients preimplementation and 1,068 patients postimplementation.

INTERVENTION:
Leapfrog intensive care unit physician staffing standard

MEASUREMENTS:
Intensive care unit and hospital length of stay, rates for ventilator-associated pneumonia and central venous access device infection, and cost of care.

RESULTS:
Following institution of the intensive care unit physician staffing, the mean intensive care unit length of stay decreased significantly from 3.5 ± 8.9 days to 2.7 ± 4.7 days, (p < .002). The frequency of ventilator-associated pneumonia fell from 8.1% to 1.3% (p < .0002) after intervention. Ventilator-associated pneumonia rate per 100 ventilator days decreased from 1.03 to 0.38 (p < .0002). After intervention, the frequency of the central venous access device infection events fell from 9.4% to 1.1% (p < .0002). Central venous access device infection rate per 1000 line days decreased from 8.49 to 1.69. The net savings for the hospital were $744,001. The 1-yr institutional return on investment from intensive care unit physician staffing was 105%.

CONCLUSIONS:
Implementation of the Leapfrog intensive care unit physician staffing standard significantly reduced intensive care unit length of stay and lowered the prevalence of ventilator-associated pneumonia and central venous access device infection. A cost analysis yielded a 1-yr institutional return on investment of 105%. Our study confirms that implementation of the Leapfrog intensive care unit physician staffing model in the community hospital setting improves quality measures and is economically feasible.

PMID: 22824939
[PubMed – as supplied by publisher]

SMACC!

I know where I’ll be from the 11th to the 13th of March 2013, Sydney!  To be fair I would probably have been in Sydney anyway because I live here.  But all that aside, Now I have a reason not to leave.  The inaugural Social Media and Critical Care conference looks like it’ll be a ripper beaut (better get used to the local dialect if you’re coming down.)

If you’re not there, everyone will be asking…

Trauma Resuscitation in the ’80s!

Here’s a nostalgia evoking clip showing the old resus room in Auckland Public (now Auckland City) Hospital (hands up who remembers them!)  Note the absence of gloves, the presence of MAST trousers and the extremely liberal use of various fluids.  A highlight must the the RN opening a bag of blood with her teeth.  Note also the very young Stephen Streat (Now A/Prof in the Auckland Dept. of Critical Care Medicine) and Ian Civil (recent past President of the Royal Australasian College of Surgeons). Fabulous.  I think it’s great looking at the way things were, it helps us to better understand where we are now and where we are going.