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Press Releases

Take a look at a selection of our recent media coverage:

Cannabis use not associated with higher incidence of respiratory-related hospital visits

4th July 2022

Cannabis use is not associated with more respiratory-related visits to an emergency department in comparison to those who do not use the drug although it is associated with a greater proportion of overall emergency department visits. This was the main conclusion of a propensity-matched study by a group of researchers from Ontario, Canada.

Cannabis (or marijuana) is the most commonly used addictive drug after tobacco and alcohol. The use of cannabis is associated with respiratory problems such as chronic bronchitis symptoms and large airway inflammation and in fact, heavy use may lead to airflow obstruction. Despite this evidence of adverse respiratory effects, a 2018 systematic review concluded that there was low-strength evidence that smoking cannabis was associated with cough, sputum production, and wheezing and that there was insufficient evidence of an association between use of the drug and obstructive lung disease. Nevertheless, one study has suggested that daily cannabis smoking, even in the absence of tobacco, is associated with an elevated risk of health care use for various health problems.

With some uncertainty over the respiratory effects of cannabis, in the present study, the Canadian team wanted to examine the magnitude of the association between the use of cannabis and adverse respiratory-related emergency department visits. They conducted a retrospective analysis linking health survey and health administrative data for residents of Ontario. Individuals who self-reported any use of cannabis (the exposed group) within the past year were matched 1:3 (to increase the sample size) with control individuals, which were those who self-reported no use of the drug. The primary outcome for the study was a respiratory-related emergency department visit or hospitalisation which included both upper and lower respiratory tract infections, respiratory failure, asthma or COPD as the reason for presentation at the hospital. As a secondary outcome, the team assessed all-cause emergency department visits.

Cannabis use and respiratory-related hospital visits

A total of 35,114 individuals were included in the analysis, of whom, 6,425 with a mean age of 32.2 years (38.8% female) were self-reported cannabis users. Overall, 42.5% of those using the drug did so less than once a month with a much smaller proportion (10.5%) reporting daily use.

The odds of a respiratory-related emergency department visit or hospitalisation was not significantly different between the exposed and control group (odds ratio, OR = 0.91, 95% CI 0.77 – 1.09, p = 0.32). Despite this, there was a greater odds of all-cause emergency department visits among those who used cannabis (OR = 1.22, 95% CI 1.13 – 1.31, p < 0.0001). The most frequent reason for the emergency visits among those using cannabis was for acute trauma (15.1%) although interestingly, this was followed by respiratory problems (14.2%).

The authors concluded that while there were no differences in the proportion of respiratory-related hospital visits between the two groups, all-cause hospital visits were significantly higher among those who. self-reported cannabis use. They added that based on these findings, recreational use of the drug should be discouraged.

Citation
Vozoris NT et al. Cannabis use and risks of respiratory and all-cause morbidity and mortality: a population-based, data-linkage, cohort study BMJ Open Respir Res 2022

Standardised radiology alert system effective for incidental findings follow-up

30th June 2022

A standardised radiology alert system has enabled the follow-up of the majority of ED patients for whom incidental findings were detected

A standardised radiology notification system which identified and subsequently ensured the follow-up of emergency department patients for whom incidental findings were detected in scans, has proved to be highly successful. This was the conclusion of a study by a team from the Department of Emergency Medicine and the Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, US.

The presence of incidental findings and which are unrelated to the initial indication for a radiological scan are not uncommon. For example, in a study of 1155 patients who had an emergency abdominal computed tomography scan, 700 had incidental findings detected, of which, 143 were deemed indeterminate requiring urgent investigations. The presence of incidental findings are commonly detected in scans for trauma patients, with some that require urgent evaluation (type 1 findings) or at least should be communicated to patients (type 2 findings). Using this classification, in one study that retrospectively reviewed 3092 patients, type 1 findings were present in 32% of all scans and type 2 findings in 41.2% of scans. Communication of findings to patients and appropriate follow-up is needed particularly where the findings indicate a potential malignancy. For the present study, the US team developed a standardised radiology reporting system that created an electronic trigger to ensure that patients with incidental radiology findings were connected with an appropriate outpatient surveillance follow-up.

The team retrospectively examined the value of their standardised radiology reporting system by including all adult emergency department visits with a critical radiology alert for incidental findings. Operationally, if a radiologist identified important clinical or incidental findings, these were added to a critical alert messaging system which activated a ‘stop sign’ icon on the emergency department, indicating to clinicians that the alert needed to be reviewed and acknowledged. The emergency department clinicians were then required to complete an appropriate follow-up request form which was sent to members of the department whose role was to liaise with patients and primary care physicians to arrange the recommended follow-up. For the present study, the authors set the primary outcome measure as the proportion of emergency department (ED) patient visits with identified incidental findings that had documented communication with the patients and surveillance plans. For the secondary outcome, the team looked at the frequencies of post-ED surveillance clinic visits.

Standardised radiology alert system outcomes

During the period of analysis, there were 64,731 ED visits of which 932 (1.44%) patient visits had critical radiology alerts. This total included 53 visits with multiple findings so that the actual total was 982 incidental findings.

The primary outcome was met in 95.3% (95% CI 93.9% – 96.6%) of ED patient visits. For the secondary outcome, 99.1% of in-network referral to a primary care provider or specialist occurred.

The authors concluded that the successful implementation of a standardised radiology notification and referral system is an important patient safety intervention that provides the opportunity to detect undiagnosed malignancies.

Citation
Barrett TW et al. Catching Those Who Fall Through the Cracks: Integrating a Follow-Up Process for Emergency Department Patients with Incidental Radiologic Findings Ann Emerg Med 2022

Incidental findings observed in almost a third of CT scans in emergency departments

27th June 2022

According to a systemic review, incidental findings seen on a CT scan in emergency departments are present in nearly a third of cases

The presence of incidental findings (IF) occurs in roughly a third of all computed tomography (CT) scans undertaken with emergency departments according to the findings of a systematic review by a group of US researchers.

The term ‘incidentaloma’ refer to an incidentally discovered mass or lesion, detected using imaging and which was performed for an unrelated reason. Such incidental findings are not uncommon, especially among scans for trauma patients with one study revealing how the findings were present in 15% of trauma CT scans. Whilst the presence of IF do not affect or alter the emergency department clinician’s current diagnostic work-up, it is important that these observations are communicated to patients so as to ensure that where necessary, appropriate further tests and follow-up are instigated. However, in non-trauma patients, little is known about the level of incidental findings among CT scans undertaken within emergency departments. For the present study, the US team sought to estimate the prevalence of radiologic IF among patients visiting an emergency department and who underwent a CT scan. A secondary aim was look at how hospitals managed and stratified the risks associated with abnormal findings.

Undertaking a comprehensive literature search, the authors looked for studies including terms such as ‘incidentaloma’ without a restriction on the type of study design and which included those that were retrospective, cross-sectional or prospective in nature. The primary outcome of the systematic review was the prevalence of IF on a CT scan.

Prevalence of incidental findings on CT scans

A total of 69 studies representing 147,763 emergency department encounters or radiology reports, with a median patient sample size of 882, were included in the analysis. The majority of studies were cross-sectional in design (82.6%) with the remainder comprising cohort (7.2%) and those with a pre- and post-interventional design. Just over half of the studies (50.7%) were in trauma patients and 63.8% of studies included some form a risk stratification of IF.

The pooled prevalence of any incidental finding on CT scan was 31.3% (95% CI 24.4% – 39.1%) although there was marked evidence of heterogeneity in the studies. The highest prevalence of IF occurred in patients having a CT scan because of chest pain (36.6%), followed by trauma (34.7%).

In a total of five studies, all based in trauma centres, there were structural interventions designed to improve the recognition and notification or follow-up of patients identified with an IF on a CT scan. In one such study, for example, following implementation of the strategy to manage IF, patient notification increased from 17.7% to 32.4%.

The researchers also discovered that documentation of IF in the patient’s discharge notes was present in only 20.1% to 47.2% of cases.

In their conclusion, the authors identified the need to establish a comprehensive classification system and standard-based approach to help clinicians when faced with an IF. They also called for more flexible care co-ordination programs to ensure timely follow-up, clear documentation in medical records and which could easily be implemented within a busy emergency department.

Citation
Evans CS et al. Incidental Radiology Findings on Computed Tomography Studies in Emergency Department Patients: A Systematic Review and Meta-Analysis Ann Emerg Med 2022

Blood lactate levels in tandem with qSOFA or NEWS provides best prediction of 28-day in-hospital mortality for patients at risk of sepsis

27th April 2022

Blood lactate measurements alongside qSOFA or NEWS improves the sensitivities of both tools for predicting 28-day in-hospital mortality

Using blood lactate levels alongside either the quick sequential organ failure assessment (qSOFA) or the National Early Warning Score (NEWS) clinical prediction tools, increases the sensitivities of both for the prediction of 28-day in-hospital mortality among emergency department (ED) patients with a suspected infection and at risk of sepsis. This was the conclusion of a study by researchers from the Department of Intensive Care, Centre Hospitalier du Mans, Le Mans, France.

The World Health Organization defines sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection adding how in 2017, the condition was responsible for around 11 million deaths worldwide, representing almost 20% of all global deaths. Moreover, early detection of sepsis with timely, appropriate interventions increases the likelihood of patient survival. Consequently, several tools have been developed to assess patients with an infection who are likely to have sepsis including qSOFA and NEWS. However, a 2018 meta-analysis found that qSOFA was associated with a pooled sensitivity of only 60.8% and a pooled specificity of 72.0% for the prediction of mortality. The NEWS can also be used for predicting intensive care unit (ICU) admission and mortality when used in an ED although a systemic review found that the NEWS area under the receiver operating characteristic curve for mortality prediction, varied from from little better than chance to a good prediction of mortality. In addition, elevated blood lactate levels (> 2.6 mmol/L) have also been found to predict 30-day in-hospital mortality in unselected patients who arrived at an ED.

Given the potential value of both tools and measurement of blood lactate levels, for the present study, the French team wondered if modification of the qSOFA and NEWS to incorporate lactate levels, would improve their respective predictive accuracy for adult ED patients with suspected infection.

The French team undertook a retrospective analysis of adult patients with suspected infection and who had blood cultures obtained within the ED and to whom a non-prophylactic antibiotic was given within the ED. They created three separate clinical prediction tools: qSOFA and NEWS alone; both tools with blood lactate levels incorporated and finally, both qSOFA and NEWS with blood lactate levels measured in tandem. Cut-off scores for qSOFA used were > 2 and NEWS > 7 and blood lactate levels > 2 mmol/L. The primary outcome measure was in-hospital 28-day all-cause mortality and the secondary outcome, 3-day all-cause mortality.

Blood lactate levels and clinical scoring outcomes

A total of 1003 patients with a median age of 76 years (57% male) were included in the study and by day 28, 13% of patients had died in hospital.

The sensitivities for 28-day mortality were 50% (qSOFA > 2), 69% (qSOFA with lactate), 77% (qSOFA and lactate in tandem). For NEWS, the corresponding sensitivities were 69% (NEWS alone), 80% (NEWS with lactate) and 87% (NEWS with lactate in tandem). In other words, using either qSOFA or NEWS and blood lactate levels in tandem, provided greater sensitivities than either of the prediction tools alone or with lactate levels incorporated into the tool. Similar results were seen for the secondary outcome of 3-day all-cause mortality.

Nevertheless, despite the improved sensitivities for both prediction tools when used alongside blood lactate levels, the corresponding specificities were 66% (qSOFA and lactate in tandem) and 46% (NEWS and lactate in tandem). This, the authors suggested meant that neither combination was an effective means of ‘ruling out’ mortality. They concluded that though using either tool in tandem with blood lactate was better than incorporating lactate levels into the tool, neither tool optimally predicted in-hospital 28-day mortality.

Citation
Julienne J et al. Prognostic accuracy of using lactate in addition to the quick Sequential Organ Failure Assessment score and the National Early Warning Score for emergency department patients with suspected infection Emerg Med J 2022

Ultrasound sensitive and specific for initial diagnosis of acute appendicitis in ED

1st April 2022

The use of ultrasound has been found to have a high sensitivity and specificity for the initial diagnosis of acute appendicitis within an ED

Using ultrasound within an emergency department is both a sensitive and specific imaging modality for the diagnosis of patients with acute appendicitis. This was the conclusion of a retrospective study by researchers from the Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland.

Acute abdominal pain accounts for between 7 and 10% of all Emergency Department (ED) visits. Furthermore, in a retrospective review of 2222 patients with acute abdominal pain who underwent contrast enhanced CT scanning within 24 hours after admission, acute appendicitis accounted for 15.9% of all cases. The diagnosis of acute appendicitis (AA) is crucial, particularly in older patients, with one study finding that among those older than 55 years of age, 29% had perforated appendicitis after 36 hours of symptoms and 67% between 36 and 48 hours of symptoms. Moreover, another study identified a perforation rate among those with appendicitis of 16 % and revealed how the cause of perforation was mostly physician-related in children and adults. It is also important to reduce the incidence of negative appendectomy (NA), i.e., the non-incidental removal of a normal appendix as there are significant clinical and financial costs incurred by patients undergoing NA during the treatment of presumed appendicitis. The gold standard imaging modality for AA is computed tomography (CT), which has been shown to have a pooled sensitivity and specificity for diagnosis in adults of 83% and 93% respectively. Though CT is the preferred diagnostic imaging technique, there are concerns over both irradiation (especially in children), access and the costs of the technique.

At the researcher’s hospital, the current practice is to initially use an ultrasound scan for a patient with suspected AA and where this is positive, the patient proceeds to surgery. In contrast, negative or uncertain scans are followed up with a CT scan. For the present study, the team undertook a retrospective analysis to evaluate their current strategy. They collected all suspected cases of AA over a 2-year period and classified the outcome of the sonographic examination as either AA; normal appendix or inconclusive. The sonography results were compared to a gold standard of either the CT result or intra-operative or histopathological findings where CT scans were not used. These results were then classed as a true positive and true negative where the ultrasound findings matched the gold standard and either a false positive or negative where the ultrasound diagnosis differed from the gold standard or finally, as inconclusive. An additional factor analysed since it might relevant, was the type of sonographer and which was categorised as either a radiologist or an experienced or inexperienced emergency care physician.

Ultrasound and diagnosis of AA

A total of 508 patients with mean ages ranging from 31.3 to 44.9 years who were scanned were included in the analysis. The prevalence of AA in the whole cohort was 34% and among the 508 patients, 308 (60.4%) had a conclusive ultrasound examination. The sonography was positive in 115 patients, of whom 103 (89.6%) had appendicitis based on the reference standard. The sonogram was read as negative for AA in 193 patients and 12 of these (6.2%) had AA based on the reference standard, i.e., were false negatives. Overall, the results suggested that ultrasound had a sensitivity for AA of 89.6% (95% CI 82.1 – 94.3%) and a specificity of 93.8% (95% CI 89.1 – 96.6%).

For the remaining 200 patients who had an inconclusive ultrasound, 29% were ultimately diagnosed with AA.

Comparison of radiographers, experienced physicians and inexperienced physicians showed that the sensitivities were 90.3%, 90.9% and 87.5% respectively. For instance, inexperienced physicians reached a definitive conclusion in 48.1% of exams compared to 76% for their experienced colleagues.

Commenting on their findings, the authors suggested that while ultrasound was able to identify AA in a large number of cases, where it was inconclusive, 29% of patients were eventually diagnosed with the condition. They concluded that while an initial ultrasound might be negative, further investigation was warranted given that 6% of cases were likely to be false negatives.

Citation
Lehmann B et al. Diagnostic accuracy of a pragmatic, ultrasound-based approach to adult patients with suspected acute appendicitis in the ED Emerg Med J 2022

Anaesthetic methods for paediatric forearm reduction lack data to support optimal choice

4th March 2022

Anaesthetic methods used in paediatric forearm reduction in emergency departments lack sufficient evidence to make specific recommendations

The different anaesthetic methods used in the closed reduction of paediatric foreman fractures currently lacks sufficient evidence to guide clinicians in their choice of treatment. The was the conclusion of a study by researchers from the Yong Loo Lin School of Medicine, National University of Singapore, Singapore.

Paediatric diaphyseal fractures of the radius and ulna (bone forearm fractures) are the third most common fracture in the paediatric population, accounting for between 13 and 40% of all childhood fractures. Anaesthesia is required to provide adequate pain relief and methods include procedural sedation and analgesia (PSA), haematoma block (HB) and intravenous regional anaesthesia (IVRA). In a 2018 systematic review of PSA and HB, the authors concluded that HB was a safe and effective alternative to PSA among adult and paediatric patients. Other anaesthetic methods include infraclavicular blocks which involve the use of anaesthetics such as lidocaine and prilocaine and residual neuromuscular block, although the comparative efficacy of these methods has not been assessed.

For the present study, the Singaporean team sought to synthesise the current evidence from randomised controlled trials to determine the most effective analgesia with respect to pain reduction within an emergency care setting for the closed reduction of paediatric forearm fractures.

All of the main databases including PubMed and EMBASE were searched and the researchers focused on randomised trials including patients under 18 years of age with a forearm fracture treated with closed reduction within emergency departments. Additional criteria applied were that these studies should involve at least one comparison of different methods. The team set the primary outcome as pain during reduction and several secondary outcomes including of pain after reduction, adverse effects, satisfaction, success of reduction.

Anaesthetic methods and pain during reduction

A total of 9 studies including 936 patients were included in the final analysis. All of the studies were single centre, randomised trials and compared different aspects including the main methods of anaesthesia, the drugs used, administration route and the use of adjuncts.

However, for the primary outcome of pain during reduction, all of the included trials were considered to be at risk of bias and consequently, given the high degree of heterogeneity, a meta-analysis of the finding was not undertaken.

In trying to pull together the disparate findings, the authors noted the infraclavicular block seemed to result in better pain outcomes, satisfaction scores and fewer cases of hypoxia compared with PSA in one of the studies. In addition, lidocaine led to better pain outcomes compared to prilocarpine when used in IVRA in another study. The researchers added that the quality of the evidence was generally low.

In their conclusion, the researchers suggested that infraclavicular block should be further investigated and that more adequately powered trials using standardised methods are required. However, there was a distinct lack of good quality evidence to inform the anaesthesia decision-making process. They suggested that more valuable evidence would likely arise after publication of the results of an on-going trial to evaluate the sedative and analgesic effects of intranasal Dexmedetomidine in children undergoing conscious sedation for reduction of closed distal forearm fractures compared to intravenous ketamine.

Citation
Goh AXC et al. Comparative efficacy of anaesthetic methods for closed reduction of paediatric forearm fractures: a systematic review Emerg J Med 2022


Early intravenous fluid use for sepsis patients in ED improved by range of interventions

4th February 2022

Early intravenous fluid use in emergency department patients with sepsis increased after implementing performance interventions

Early intravenous fluid use in sepsis patients seen at emergency departments has been found to increase after the introduction of several improvement interventions. This was the conclusion of a study by a team from Western Sydney University, School of Nursing and Midwifery, Australia.

Sepsis is a syndrome of physiologic, pathologic and biochemical abnormalities which is induced by infection. Although the global burden is difficult to ascertain with a high degree of certainty, the World Health Organization reports that in 2017, there were an estimated 48.9 million cases and as many as 11 million sepsis-related deaths globally.

Early intravenous fluid resuscitation is crucial for stabilisation of sepsis-induced tissue hypo-perfusion or septic shock and has been recommended by the ‘Surviving Sepsis Campaign’ guideline in 2017. In the latest update, it is recommended that crystalloid fluid should be given within the first 3 hours of resuscitation.

The Australian team wondered to what extent any interventions to improve early intravenous fluid administration might improve compliance with the sepsis guidelines and set out to find an examine the value of any such interventions. The team undertook a literature search for studies in adults presenting at an emergency department with sepsis and included those trials where the purpose of the intervention or strategy was to influence early intravenous fluid administration, for example, through educational programs, sepsis alerts or inclusion in sepsis protocols.

Findings

A total of 31 studies were included in the analysis. In 15 of these studies with a total of 1538 patients assigned to the intervention arm, the summary estimate indicated a 47% improvement in the rate of compliance with early intravenous fluid use (relative risk, RR = 1.47, 95% CI 1.25 – 1.74, p < 0.01).

The mean difference in time to initiation of early fluids was – 24.11 minutes, i.e., an average reduction of 24 minutes in the time to fluid resuscitation between intervention and control groups. Similarly, patients received an average additional 575 ml of fluids within the protocol recommended time as a result of the intervention.

In discussing their findings, the authors reported how early intravenous fluid administration compliance increased by an average 47% and more importantly, this improvement was seen in a variety of emergency departments across the world. The authors described how there were a range of interventions employed which ranged from educational to process change measures such as a multidisciplinary sepsis program.

They concluded that performance improvement initiatives appeared to significantly improve compliance with early intravenous fluid administration and called for future studies to examine the subjective factors influencing the use of an early fluid bolus.

Citation

Kabil G et al. Early fluid bolus in adults with sepsis in the emergency department: a systematic review, meta-analysis and narrative synthesis BMC Emerg Med 2022

Delayed inpatient admission in excess of 5 hours from the ED linked to higher 30-day mortality

3rd February 2022

Delayed inpatient admission from an ED in excess of 5 hours has been found to be associated with a higher 30-day all-cause mortality

Delayed inpatient admission from an emergency department (ED) for longer than 5 hours leads to a greater 30-day mortality. This was the conclusion of a study by a team from the Department of Population Health, New York University School of Medicine, New York, US.

In England, the NHS has a 4-hour operational standard which is a binary time threshold such that patients who remain in ED for longer than 4 hours are deemed to have ‘breached’ the target. There are potentially many reasons why patients have a delayed inpatient admission though one factor identified from research which correlates with a higher ED waiting time is higher inpatient bed occupancy. In addition, some data shows that a longer mean length of stay within the ED, is associated with a greater risk of short term mortality and admission to hospital in patients who are well enough to leave the department.

For the present study, the US team turned to a large NHS database to examine whether delayed inpatient admission was associated with an increased risk of mortality. They used a cross-sectional, comparative, retrospective design and included all patients admitted from ED and measured the time from the patient’s arrival at the ED until their transfer to an inpatient bed. They set the primary outcome as death from all causes within 30 days of hospital admission. The team collected data over a 2-year period including patient demographics, including co-morbidities and demographics, together with temporal factors such as month of admission, time of admission. Regression analysis which adjusted for factors such as age, co-morbidities etc, was used to model expected and observed mortality.

Findings

A total of 26,738 514 people visited an ED during the two-year study period but data was available for only 5,249,891 admitted patients and who were included in the analysis. Among this group of delayed inpatient individuals, there were 433,962 deaths within 30 days, giving a crude 30-day mortality rate of 8.71%. The mean time spent in ED was just under 5 hours and the 4-hour breach rates averaged around 38%.

In regression analysis, the risk of death increased in a linear fashion from 5 hours after time of arrival in ED up to 12 hours. The factor with the highest risk of 30-day mortality was the 4-hour breach (odds ratio, OR = 1.35, 95% CI 1.33 – 1.37, p < 0.001).

Commenting on these findings, the authors described how there was a ‘dose-dependent’ association between delayed inpatient admission in excess of 5 hours in the ED and 30-day mortality. They calculated that one extra death occurs for every 82 patients who are delayed for more than 6 to 8 hours in the ED and concluded that healthcare policy makers should mandate timely admission from ED to avoid hospital-associated patient harm.

Citation

Jones S et al. Association between delays to patient admission from the emergency department and all-cause 30-day mortality Emerg Med J 2022


Pharmacist-led antimicrobial stewardship ensures appropriate prescribing in EDs

2nd February 2022

Pharmacist-led antimicrobial stewardship within emergency departments appears to be effective and improve adult antibiotic prescribing

Pharmacist-led antimicrobial stewardship with emergency departments is associated with more appropriate antibiotic prescribing in adults who present with a range of infectious conditions. This was the conclusion of a systematic review and meta-analysis by a team from the Department of Pharmacy and the Department of Emergency Medicine, Mayo Clinic, Minnesota, US.

Research from the US suggests that an estimated 30% of outpatient, oral antibiotic prescriptions may have been inappropriate, highlighting a need for effective antimicrobial stewardship programs within an emergency departments. However, one systematic review addressing this topic concluded that while such interventions may improve patient care, the optimal combination of interventions is unclear. While the review did not consider pharmacist-led interventions, other reviews have demonstrated that within an inpatient setting, pharmacist-led educational antimicrobial stewardship interventions are effective at increasing guideline compliance and reducing duration of antimicrobial therapy. Although prior research has demonstrated that a clinical pharmacist within an emergency department is of value, the impact of a pharmacist-led antimicrobial stewardship program within emergency departments remains unknown.

For the present study, the US team set their primary aim as an assessment of the impact of pharmacist-led antimicrobial stewardship interventions, on the appropriateness of antibiotic prescribing within emergency care settings. The secondary aim was to assess the impact of any such interventions on time to culture review, time to appropriate antibiotics and emergency care return rates.

Findings

The literature review identified 22 studies including 5,062 patients that were suitable for analysis, the majority of which were retrospective observational cohorts, including before and after assessments though there were no randomised, controlled trials.

The nature of the studies varied and interventions included pharmacist-led culture reviews, the presence of a pharmacist in the department, pharmacist directed clinical algorithms, clinician education and one prospective antibiotic review.

In an assessment of appropriate versus inappropriate antibiotics, the pooled odds ratio (OR) was 3.47 (95% CI 2.39 – 5.03) when chosen by a pharmacist during the intervention. For specific conditions, appropriate antibiotic selection was more appropriate with pharmacist involvement for pneumonia (OR = 3.74) and urinary tract infections (OR = 1.76).

In subgroup analysis, the presence of a pharmacist led to improvements in each of the areas examined. For example, pharmacist presence within the department for antibiotic selection was better than no pharmacist for appropriate antibiotic selection (OR = 3.13), culture review (OR = 2.22) and pharmacist directed algorithms and clinical education (OR = 5.23).

However, the time to culture review and time to patient contact were no different with or without a pharmacists, although the time to appropriate antibiotic was significantly shorter in the presence of a pharmacist (mean difference 18.86 hours).

The authors concluded that the presence of a pharmacist or pharmacist-led antimicrobial stewardship interventions appeared effective for ensuring appropriate prescribing of antibiotics in adult patients presenting to emergency departments despite how the majority of included studies had a moderate risk of bias.

Citation

Kooda K et al. Impact of Pharmacist-Led Antimicrobial Stewardship on Appropriate Antibiotic Prescribing in the Emergency Department: A Systematic Review and Meta-Analysis Ann Emerg Med 2022

Standalone AI reader could significantly reduce radiologist workload in lung cancer screening

13th January 2022

A standalone AI reader outperformed four experienced radiologists in CT lung cancer screening and could reduce their workload by over 80%

Using a standalone artificial intelligence (AI) reader for lung cancer screening with ultra low-dose computed tomography (ULDCT) could potentially reduce the workload of radiologists by over 80%. This was the conclusion of a study by a team from the Department of Epidemiology, University of Groningen, Groningen, The Netherlands.

Lung cancer was responsible for 2.21 million cases and 1.8 million deaths in 2020 and volume-based, low-dose CT screening of high-risk patients has been shown to significantly reduce lung-cancer mortality compared to those who underwent no screening. Moreover, low-dose CT lung cancer screening has become an evidence-based reality. However, the introduction of such screening will undoubtedly create an enormous increase in the workload of radiologists and while the use of a standalone AI as a second reader for lung cancer screening with CT has shown much promise, how well an AI system could perform as a standalone system remains uncertain.

For the present study, the Dutch researchers, sought to evaluate the performance of a standalone AI as an impartial reader in ULDCT lung cancer baseline screening compared to that of experienced radiologists and a consensus read reference standard. They used a dataset of CT scans from participants who underwent a baseline scan and who were found to have at least one solid nodule of any size in their scan. Other inclusion criteria for the study were: participants aged 50 – 80 years, > 30 pack-years smoking history, current or former smoker and those who did not develop lung cancer within two years of their baseline scan. All of the participant’s scans were independently analysed by five thoracic radiologists and the standalone AI then independently analysed all the scans to detect, measure and classify nodules. In addition, an independent consensus read was performed by a panel of three, experienced radiologists and who sought to determine the number of positive misclassifications (PM) and negative misclassifications (NM). A PM was classified as nodules > 100 cubic mms and NM < 100 cubic mms. The results from the 5 radiologist reader and the standalone AI were compared to the consensus read to determine the number of PM and NM results as well as the number of discrepancies.

Findings

A total of 283 participants with a mean age of 64.6 years (56.9% male) with a total of 1149 lung nodules were analysed.

The consensus read was 83 PMs and 200 NMs and the standalone AI had 61 discrepancies (53 PM and 8 NM) compared to a total of 43, 36, 29, 28 and 50 from the five respective radiologists. From these results, the authors calculated that when using a standalone AI as the main reader for general lung cancer screening, there would be a workload reduction of between 77.4% and 86.7%.

The authors concluded that a standalone AI could significantly reduce the workload of radiologists in lung cancer screening.

Citation

Lancaster HL et al. Outstanding negative prediction performance of solid pulmonary nodule volume AI for ultra-LDCT baseline lung cancer screening risk stratification. Lung Cancer 2022