Feb 8, 2019

Extra hand

The story

Scribes would definitely make your life easier, but do they improve productivity? Here’s how attending-scribe pairs handled patient turnover in Australian EDs.

The background

About 25% of US emergency department physician shifts use clinical scribes, and it’s clearly a trend on the rise. Scribes, whose clerical duties are a laundry list of your worst memories from intern year, free physicians from paperwork so they can spend more time with direct patient care. Limited data shows that patients don’t mind scribes and docs like them a lot. But in the eyes of the hospital, everything is measured against the bottom line. Are scribes cost-effective?

The study

Scribes helped ED physicians see an additional 0.2 patients per hour and decreased ED length of stay by 19 minutes per patient, says a randomized trial of productivity with and without scribes in 5 Australian EDs. Gains were mainly seen in increased primary consultations. When accounting for scribe salary and training in the context of improved attending productivity, a cost-benefit analysis found a pro-scribe savings of $26 per hour. There was even some evidence that an extra pair of eyes helped prevent medical errors.

The takeaway

Scribes are only cost-effective in the context of attending salaries, so don't expect one on your next overnight shift. Look for upcoming trials to evaluate these results in US EDs.

Say it on rounds

When you wake up at 5 on your day off

Habits are hard to change. Standard treatment of bone and joint infections includes a prolonged course of IV antibiotics, though the need for parental therapy has never been proven. OVIVA randomized 1,050 patients to receive either oral or IV antibiotics during the first 6 weeks of management of complex orthopedic infections. No difference was found in rates of treatment failure at 1 year, and oral therapy patients spent fewer days in the hospital. About a quarter of patients in both groups had serious adverse events, so patients on oral antibiotics will still need close monitoring.

When you can't connect to a working printer

Machines are getting smarter, we promise. Researchers used machine learning algorithms to find the best predictors of sepsis for 3 million retrospective ED visits across 49 hospitals. The resulting scoring system, named Risk of Sepsis (RoS), was 68% sensitive for sepsis at 1 hour after presentation and 85% at 24 hours. Results surpassed common metrics like SOFA and qSOFA. Lactate, shock index (HR / SBP), and age were key model features. Prospective studies are up next. 
Ann Emerg Med

When a blown up ED means late afternoon admissions

It helps to know what's on deck. A look at cancer incidence among young adults between 1995 and 2014 found an increase in 6 of 12 obesity-related cancers despite a fall in the incidence of smoking and infection-related malignancies. Increases were steeper with younger age. With the ongoing obesity epidemic, experts worry that the future burden of obesity-related cancers may halt or reverse recent progress in cancer-related mortality. 
Lancet Public Health

Brush up

Acute infection and myocardial infarction (MI)

Almost all infections increase the short term risk of MI. A case series published last year found that the incidence of MI was up to 6x higher in the 7 days after flu and other respiratory viral infections. For bacterial pneumonia, risk of MI correlates with illness severity and can remain above baseline for up to 10 years after resolution of infection. A host of infection-associated factors – inflammatory cytokines, activated platelets, systemic stress – are thought to play a mechanistic role.

Get meta

With vaccines and cardioprotection. A 2013 analysis of 6,700 high-risk cardiovascular patients across 6 studies found that those vaccinated against the flu were 35% less likely to have a composite of CV events than unvaccinated patients over median follow-up of 8 months. In patients with a recent ACS event, the number needed to vaccinate to prevent 1 CV event was 8.

What your bioengineering friends are talking about

The Tumor Monorail tricks brain cancer cells (see video) into leaving the skull through an external tube in a process akin to a cancer Pied Piper. The device, so far only tested in rats, received breakthrough designation from the FDA this week.   

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