Posts Tagged risks and benefits

How I Missed The 6 Hour Pneumonia Antibiotics Window

When you come in morbidly obese, in this corner, weighing in at 350+ pounds and your physician is having to confirm that you will not break the CT scanner, let’s all just admit that everything gets a lot harder: making diagnoses, finding veins, dosing medications.

When you’re a nonsmoker, nonasthmatic morbidly obese person who comes in short of breath with leg swelling for the past several days, you’re on Lasix at home, and you’ve got some wheezing in your gigantic lung fields, and your chest x-ray looks like pulmonary edema, your doctor thinks he’s made the diagnosis.

But you’re very hypoxic — O2 sat in the 70s on room air — even after 6 hours in the ED, after lasix and some nitroglycerin. So we scan you for pulmonary embolus, worried about a PE. You have no PE, not really much pulmonary edema, but you have evidence of pulmonary hypertension (hi, obstructive sleep apnea) and a small consolidation, even without cough, or fever rectally, we hang your classic ceftriaxone/azithromycin. Missed that all important “6 hour window.”

And thus, our rant begineth.

Similar to my medical errors rant, I think a lot of emergency physicians have problems with these guidelines, which are described as quality indicators and let the public evaluate a hospital based on these guidelines. This assumes that a score of “100%” is the absolute best score for a hospital. So, batter up:

  1. Hey! Medicare! These are guidelines. Not rules. These are to help us physicians guide our therapy, not to control it for us. Individual patients come with individual problems that cannot always be boiled down in a document.
  2. Give humans (in this case, physicians) a perverse incentive, and we’ll start acting perverse. This can go in two ways.
    • Don’t want to be dinged for not giving antibiotics on time? Admit the patient with a diagnosis of “shortness of breath” instead of “pneumonia.” If you’re not in the inclusion criteria, you’ll sneak right by. (I’m not suggesting that physicians actually do this in practice, just giving an example.)
    • Want to make sure you meet those all-important guidelines? Maybe there’s an “early pneumonia,” or the diaphragm’s a little hazy on a portable film? Just give antibiotics to cover your ass (and your hospital’s), even though it might not be what’s best for the patient (example: the patient with hyponatremia who just last week finished a 2-month long battle with C. diff.)
  3. Scientific evidence indicates that the following process of care measures represent the best practices for the treatment of community-acquired pneumonia. Higher scores are better. Okay, so, what’s the data say?
    • One of the leading advocates of this is Dr. Peter Houck, who’s done a bunch of research showing better outcomes with early antibiotic administration. The problem? It’s all retrospective, data-mining from large data sets. (A huge slide deck from Dr. Houck from 2006 provides some rebuttals to this argument.) The data also shows that there’s a difference between antibiotics at before versus after 8 hours; perhaps the magic 6 hour window is a compromise?
    • Another “quality measure” is blood cultures before antibiotics given. And this one is simply just foolish. Antibiotics for pneumonia rarely if ever change clinical practice. This has been shown in multiple studies, from the pulmonology literature to the British Emergency Medicine literature (“30 (1.4% of all cultures) were “true positives” and 4 (0.18%) influenced subsequent patient management.”). Also multiple studies in our own Emergency Medicine journals refuse the need for cultures, too. They rarely, if ever change clinical management, yet they’re “quality indicators.” We might as well have a guideline to order ESR/CRP on patients with suspected pneumonia, too. Give me a break.
  4. And finally, the concept of an acceptable miss rate is — unacceptably — missing from the discussion. Like the general surgeon who misses a few appies or who removes a few normal ones, we should be wary of anyone that reports or preaches 100% compliance to some of these guidelines: are these physicians thinking about risks and benefits and weighing options, or just blindly following? Should we aim toward always getting things right 100% of the time? Absolutely. But the real and theoretical worlds collide. There probably is some small benefit for early antibiotics, and most people most of the time should get them earlier rather than later. (We already have incentives to do this: they can leave the ED faster and move to the floor!) But there should always be a small percentage of cases that don’t fit inside the 95% confidence interval (usually around 5% of them): a group of people who live outside the standard deviations. Aspirin for an MI? Almost always. But how about the MI with the GI bleed with the hematocrit of 10? Or the patient with the anaphylactic aspirin allergy? Risk, benefit. No right answer.

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The 95 Year-Old Slam Dunk Admission

courtesy cc license by jonrawlinson

courtesy cc license by jonrawlinson

It’s often bragging rights to the doctor who can discharge the 90+ year-old patient to home, because they’re just so likely to have something, and it’s viewed as so risky to send them out. (Similarly for the HIV patient or the renal patient; bonus points for being able to send the 95 year-old HIV+ renal patient home.) And you’re never going to hear someone complain about it being a bogus admission, even if labs are normal. You get to a certain age where you’re just allowed to say whatever you want, and if you say it in triage, you’re coming in.

But ironically, the group with the highest odds of having something seriously wrong with them are probably also the most likely to have something go wrong with them while they’re in the hospital. Benzos in the elderly, for example, have been implicated in cognitive impairment, increased falls, and more side effects than in younger patients (PDF), probably because of changes in CNS receptors and changes in metabolism. Even without benzos, they’re more likely to experience delirium or to sundown. And when they get these side effects, they’re more likely to fall, and when they fall, they’re more likely to break a hip or get a subdural, and when they do those things, they’re less likely to have a good outcome. If you give a mouse a cookie, et cetera.

That’s why, when possible, I think a discussion with the patient and his or her family members is better than a simple “He’s coming in,” dispo, no matter how mentally satisfying an auto-disposition is. There’s the obvious cases, and the few who can obviously go home, but I think there’s probably more patients in the grey area that I don’t even consider. Last week a friend in California was telling me about a chest pain and syncopal patient duo of 90-somethings he had discharged after a conversation with the family — even with an initially elevated troponin in one of them. They didn’t want a cath, or more medications, or heart surgery even if it meant the patient was having a heart attack. I probably wouldn’t want any of those interventions at that age, either. Discharge home.

I’m one of those crazy guys who thinks dying by code in a hospital bed or sedated with tubes in every orifice in an ICU just isn’t what people want, if they have enough experience with the health care system to know what those terms mean. (90% of Americans when surveyed want to die at home, but 80% die in an institution.) I’m also crazy enough to think that often if you’ve made it to 90, you probably don’t want to spend any miniscule percentage of time in the last days, months, or years of your life in a hospital. I certainly admit the vast majority of my elderly patients, but who knows, maybe many of them wouldn’t even want what the inpatient team might be able to offer them in terms of diagnosis or treatment.

Whenever I’m discussing a treatment or procedure with a patient, or getting consent, I often talk about how I believe the benefits of it outweigh the risks; that we in medicine above all try to do no harm (ha!). But this same criteria is often glossed over when deciding to admit a patient, ignoring the potential complications of any hospital admission: falls, nosocomial infections, medication errors, etc. Why do we often minimize these? Perhaps because we don’t know the true risks of a hospital admission? Perhaps because we don’t like the cognitive dissonance that in a profession of healing, in a place of healing, we can actually cause harm. Perhaps because it’s easier not to consider the risks?

In medicine, everything — and I mean everything — comes with a risk and benefit profile. And in considering admission, we need to consider what our patient would want, when feasible and possible.

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