TTHealthWatch
is
a
weekly
podcast
from
Texas
Tech.
In
it,
Elizabeth
Tracey,
director
of
electronic
media
for
Johns
Hopkins
Medicine
in
Baltimore,
and
Rick
Lange,
MD,
president
of
Texas
Tech
Health
El
Paso,
look
at
the
top
medical
stories
of
the
week.
This
week’s
topics
include
boarding
in
the
emergency
department
(ED),
attempts
to
clear
secretions
in
ventilated
patients,
cold-stored
platelets,
and
devices
to
do
CPR.
Program
notes:
0:35
Devices
to
do
CPR
versus
manual
1:37
About
60%
of
U.S.
population
2:32
8%
to
9%
survive
with
favorable
neurologic
status
3:15
Ventilated
patients
and
reduction
of
mucous
secretions
4:15
Duration
of
ventilation
unchanged
5:15
Regulate
or
expectorate
5:40
Boarding
ED
patients
6:45
Adults
admitted
to
general
medicine
service
7:45
More
common
in
older
patients
8:45
Can
initiate
inpatient
management
9:24
Cold-stored
platelets
versus
room
temp
10:24
Hemostatic
efficiency
score
11:30
Historically
used
in
cancer
patients
12:45
End
Transcript:
Elizabeth:
Should
we
be
treating
mucus
in
people
who
are
ventilated
in
the
ICU
[intensive
care
unit]?
Rick:
Boarding
emergency
department
patients.
Elizabeth:
Can
we
chill
platelets
and
get
the
same
result
as
those
kept
at
room
temperature?
Rick:
And
do
mechanical
CPR
devices
result
in
better
outcomes?
Elizabeth:
That’s
what
we’re
talking
about
this
week
on
TTHealthWatch,
your
weekly
look
at
the
medical
headlines
from
Texas
Tech
University
Health
Sciences
Center
in
El
Paso.
I’m
Elizabeth
Tracey,
a
Baltimore-based
medical
journalist.
Rick:
And
I’m
Rick
Lange,
president
of
Texas
Tech
Health
El
Paso.
Elizabeth:
Rick,
I
think
I
am
so
intrigued
by
this
study
in
Circulation
on
devices
that
are
supposedly
helpful
for
people
who’ve
had
a
cardiac
arrest.
Rick:
The
American
Heart
Association
has
made
it
very
clear
that
high-quality
CPR
is
a
critical
link
in
the
chain
of
survival
for
people
that
have
had
an
out-of-hospital
cardiac
arrest,
what
they
call
OHCA.
Unfortunately,
CPR
is
often
suboptimal
and
there’s
been
a
recent
push
to
use
mechanical
CPR
devices
as
a
way
to
mitigate
some
of
that
variability
in
how
CPR
is
performed.
And
interestingly
enough,
these
devices
were
rarely
used
before
2013,
moderately
used
before
2019,
and
then
during
COVID
there
was
a
rapid
expansion
because
of
concerns
that
the
EMS
[emergency
medical
services]
individuals
could
catch
COVID
infections
from
people
that
they
may
be
resuscitating.
So
from
2019
on,
there
was
a
proliferation
of
them,
but
there
have
never
been
any
good
studies
that
assess
whether
they’re
more
efficacious
than
routine
CPR.
And
that’s
what
this
study
attempted
to
do.
It
used
the
Cardiac
Arrest
Registry
to
Enhance
Survival.
It
encompasses
approximately
60%
of
the
U.S.
population
and
it
catches
about
200
million
residents
across
the
United
States.
They
looked
at
both
survival
and
then
individuals
that
survived
with
minimal
neurologic
deficit
before
mechanical
devices
were
available
in
those
hospitals
that
never
used
them
and
in
those
hospitals
that
subsequently
ended
up
using
them.
Over
52,000
patients
had
an
out-of-hospital
cardiac
arrest
at
73
different
agencies
they
looked
at.
And
what
they
discovered
was
that
in
those
that
did
not
use
mechanical
CPR,
there
was
no
difference
in
outcome
or
outcome
with
minimal
neurologic
deficit.
And
in
those
centers
that
used
mechanical
devices
2
years
before
and
2
years
after
the
devices,
again,
there
was
no
improvement.
Overall,
it
looks
like
the
survival
to
hospital
discharge
is
about
11%
to
12%,
with
favorable
neurologic
outcome
about
8%
to
9%,
regardless
of
whether
a
mechanical
CPR
device
was
used.
Elizabeth:
I
actually
think
this
is
good
news.
Performing
CPR
is
something
that
virtually
anybody
can
do
and
has
been
shown
previously
that
bystander-initiated
CPR
improves
survival.
I
think
the
fact
that
you
don’t
have
to
use
a
device,
all
you
need
are
your
hands,
and
you
can
be
able
to
do
this
pretty
effectively.
Rick:
Hands
and
proper
instruction,
Elizabeth.
We
can
do,
as
you
mentioned,
it
just
as
well
manually.
We
need
to
do
a
better
job
of
instructing
people
how
to
do
it
and
then
reminding
them
that
the
earlier
it’s
initiated,
the
more
likely
there
is
to
be
survival
and
survival
with
a
favorable
outcome.
Elizabeth:
Let’s
turn
from
here
to
the
New
England
Journal
of
Medicine
and
let’s
take
a
look
at
people
who
have
acute
respiratory
failure
and
are
ventilated,
and
whether
we
should
be
using
anything
to
try
to
reduce
the
mucus
secretions
that
they
frequently
produce
when
mechanical
ventilation
is
utilized.
This
is
a
study
that
had
a
2×2
factorial
design
that
had
these
critically
ill,
mechanically
ventilated
patients
who
were
16
years
of
age
or
older
who
had
acute
respiratory
failure
and
difficult-to-clear
secretions.
What
the
question
was
was
whether
carbocisteine,
which
was
administered
three
times
daily
enterally,
or
nebulized
hypertonic
saline
4
mL
four
times
daily
were
helpful
in
clearing
these
secretions
and
improving
outcomes.
And
in
this
4×4
design,
they
did
each
of
these
agents
alone,
they
used
both,
and
then
they
just
used
placebo.
Their
primary
outcome
was
the
duration
of
mechanical
ventilation
—
that’s
from
their
randomization
to
their
first
successful
unassisted
breathing.
Almost
2,000
participants
underwent
randomization.
The
upshot
of
the
whole
thing
is
that
nope,
carbocisteine
and
hypertonic
saline,
neither
one
of
them
were
helpful
in
this
outcome
of
trying
to
reduce
the
number
of
days
on
mechanical
ventilation.
And
they
did
have
more
upper
GI
[gastrointestinal]
bleeding
with
carbocisteine
and
bronchoconstriction
with
the
use
of
the
hypertonic
saline.
So
there
were
some
negative
things
that
were
associated
with
their
use.
So
it
says,
hey,
don’t
do
it.
A
lot
like
our
previous
study,
an
intervention
that
really
doesn’t
help.
Rick:
I
was
surprised
at
this
because
more
than
80%
of
the
ICUs
around
the
country
use
either
one
or
both
of
these
agents.
And
approximately
20%
to
30%
of
patients
on
mechanical
ventilation
receive
one
or
both
of
these
agents.
These
individuals
are
predisposed
to
having
secretions
that
are
difficult
to
clear.
So
it’s
thought
if
you
could
regulate
those
secretions,
that’s
what
the
carbocisteine
does,
or
if
you
had
an
expectorant,
that’s
what
the
hypertonic
saline
does,
is
that
you
can
clear
those
secretions
better
and
the
outcome
would
be
better.
More
specifically,
they’d
spend
less
time
on
the
ventilator
and
be
easier
to
wean.
But
as
you
suggest,
in
this
very
well-done
study
of
almost
2,000
individuals,
neither
of
those
agents
was
helpful.
And
in
fact,
they
were
both
associated
with
harms.
Elizabeth:
We
like
those
negative
studies
because
they
tell
us,
like,
yet
one
more
thing
we
don’t
have
to
do.
Why
don’t
we
turn
from
here
to
JAMA?
Rick:
I
teed
this
up
as
boarding
emergency
department
patients.
That’s
the
practice
of
once
you
have
a
patient
in
the
emergency
department
and
you
decide
you’re
going
to
admit
them
to
the
hospital,
oftentimes
they
spend
additional
time
in
the
emergency
department,
they’re
boarding
there,
before
they
ever
get
up
to
the
hospital
bed
for
a
number
of
reasons.
Sometimes
there
aren’t
enough
beds
in
the
hospital.
It’s
a
staffing
issue.
It’s
a
change
of
shift.
But
evidence
has
shown
that
the
longer
that
a
patient
boards
from
the
emergency
department,
the
more
likely
they
are
to
have
complications
related
to
that
and
adverse
outcomes.
So
what
you’d
like
to
do
is,
once
the
person
is
admitted,
is
to
get
them
up
to
the
hospital
room
as
quickly
as
possible
because
that’s
when
care
is
initiated.
So
that
person
oftentimes
is
in
limbo
in
the
emergency
department.
The
emergency
department
has
wiped
their
hands
clean,
saying
we’ve
admitted
this
patient,
but
the
physicians
actually
haven’t
written
orders
yet.
What
this
study
did
was
it
tried
to
assess
the
time
delay
from
when
the
patient
is
decided
to
be
admitted
to
when
initial
orders
are
written,
or
they
end
up
leaving
the
emergency
department.
So
they
looked
at
17
different
health
systems
across
the
U.S.
in
a
1-year
period
from
June
of
2024
to
May
of
2025.
And
they
looked
at
adults
that
had
been
admitted
for
general
medicine
service.
They
looked
at
over
3.2
million
emergency
department
visits.
Fifty-four
percent
experienced
boarding
of
at
least
4
hours
in
the
emergency
department
while
awaiting
an
inpatient
bed.
What
percentage
of
those
individuals
were
not
receiving
inpatient
care?
About
17%
experienced
a
delay
of
at
least
4
hours,
5%
a
delay
of
12
hours,
and
1%
a
delay
of
24
hours
without
any
inpatient
management
in
the
emergency
department.
When
they
looked
at
all
these
different
health
systems
and
all
the
different
hospitals
involved,
about
half
a
percent
of
admitted
patients
were
exposed
to
at
least
12
hours
without
any
inpatient
management
and
about
one
in
1,000
at
least
24
hours
without
inpatient
management.
It
was
more
common
to
have
this
delay
in
inpatient
care
in
academic
hospitals,
hospital
with
more
beds,
those
with
better
Medicaid
share,
and
they’re
more
likely
to
involve
older
patients,
Medicare,
and
high-acuity
patients.
We’ve
got
to
be
better
about
providing
inpatient
care,
especially
in
the
settings
that
I
mentioned.
Elizabeth:
The
patient,
because
they’re
in
limbo,
their
insurance
company
says
like,
hey,
we’re
not
going
to
pay
for
this,
or
we’re
only
going
to
pay
for
this
level
of
care.
And
meanwhile,
the
hospital
is
in
another
place.
And
we
understand,
of
course,
this
whole
backup.
And
my
understanding
of
it
is
that
we
have
fewer
skilled
nursing
facilities.
We
can’t
get
patients
out
of
the
hospital
promptly
so
that
they
can
go
to
the
skilled
nursing
facility.
Therefore,
they’re
stuck
in
the
hospital.
So
the
beds
aren’t
freeing
up.
So
the
patients
who
need
them
are
then
stuck
in
the
ED.
And
at
least
one
of
my
colleagues
has
quipped
that,
at
least
for
patients
who
have
a
psychiatric
diagnosis,
if
you
were
boarding
in
the
ED
and
you
were
presumed
psychotic
when
you
came
in,
you
sure
would
be
after
a
few
days
of
being
boarded
in
there.
Rick:
Part
of
it,
again,
is
availability,
but
there’s
still
opportunities
to
initiate
inpatient
management,
even
if
the
patient
hasn’t
been
brought
up
to
the
floor.
And
that’s
the
gap,
I
think,
we
need
to
make
sure
that
we
address.
OK,
the
patient’s
been
admitted.
The
admitted
physician
hasn’t
written
the
orders
yet,
but
they’ve
been
discharged
from
the
emergency
department,
but
there’s
that
gap
there.
And
we
need
to
make
sure
that
we
can
initiate
inpatient
care
during
that
time,
either
from
a
team
that’s
dedicated
to
the
ED
but
managing
these
patients,
or
to
have
the
inpatient
team
provide
that
care,
although
it’s
difficult
to
do
when
you’re
geographically
distant
from
the
emergency
department.
Elizabeth:
It
sounds
like
a
new
specialty
to
me,
a
lot
like
hospitalist.
It’s
like
the
emergency
departmentist
of
some
type.
Rick:
Hit
the
nail
on
the
head
there.
Elizabeth:
We’re
going
to
see
that
coming,
but
with
a
better
name,
I
hope.
Finally,
let’s
turn
to
this
notion
of
chilling
platelets.
This
was
an
education
for
me
that
platelets,
which
are
really
routinely
used
for
people
who
have
a
bleeding
potential,
or
are
frankly
bleeding,
are
normally
stored
at
room
temperature.
And
there’s
a
whole
protocol
that’s
associated
with
their
storage,
and
that
they
have
to
be
shaken
and
then
they
have
to
be
maintained
and
they
have
a
very
short
duration
of
time
that
they’re
useful,
which
is
5
to
7
days.
They
can
be
stored,
though,
in
cold
storage.
And
this
study
is
looking
at,
gosh,
will
that
allow
us
to
have
a
longer
storage
duration,
but
not
lose
any
hemostatic
function?
They
decided
they
wanted
to
look
at
cold
storage
up
to
21
days
for
cold-stored
platelets
and
see
whether
they
were
non-inferior
or
superior
in
comparison
to
the
room-temperature
platelets.
And
they
were
doing
this
in
actively
bleeding
patients
who
were
undergoing
cardiac
surgery
with
cardiopulmonary
bypass.
This
is
a
phase
III,
multicenter
study.
Their
primary
outcome
was
the
hemostatic
efficiency
score,
with
values
ranging
from
1
to
5,
with
higher
values
indicating
greater
bleeding.
They
wanted
a
non-inferiority
of
at
least
97.5%.
And
their
secondary
outcome
was
24-hour
chest
tube
output.
They
had
almost
1,000
patients
in
this
primary
analysis,
quite
a
few
really
young
children,
28
days
and
older.
The
cold-storage
platelets
were
non-inferior
to
the
room-temperature
platelets
for
the
primary
outcome,
with
a
probability
of
greater
than
99.9%
for
all
cold-storage
durations.
Similarly,
this
chest
tube
output
was
really
not
significantly
different
between
these
different
groups.
It’s
sure
looking
like
it’s
time
to
change
the
technology,
at
least
in
this
group
of
patients.
And
the
editorialists
suggest
that
in
other
groups
of
patients,
like
people
with
cancer
who
also
require
platelets,
that
we
need
to
be
exploring
that
also.
Rick:
Historically,
the
reason
this
came
about
is
because
we
used
platelets
in
cancer
patients
because
the
chemotherapy
decreases
their
platelet
count.
And
when
they
tested
room-temperature
versus
cold-stored
platelets,
the
room-temperature
tended
to
survive
longer
when
they
were
infused
in
cancer
patients.
That’s
just
by
platelet
numbers.
But
what
we
really
care
about
is
does
it
actually
stop
the
bleeding?
And
that’s
what
this
study
did.
It
took
individuals
that
were
bleeding
after
cardiothoracic
surgery
and
said
room-temperature
versus
cold,
is
there
any
difference?
And
there
was
no
difference
between
the
two.
The
room-temperature
ones
last
for
a
short
period
of
time,
have
a
high
risk
of
infection
because
they’re
stored
at
room
temperature.
The
cold
ones
require
less
processing.
They’re
less
fragile.
They
last
for
a
longer
period
of
time.
They’re
less
likely
to
cause
infection
because
we
can
store
them.
They’re
less
likely
to
be
thrown
away.
All
of
this
is
very
good
news
in
terms
of
making
better
use
and
less
expensive
platelets
for
individuals
undergoing
cardiothoracic
surgery.
And
now
we
need
to
extend
this
to
other
patient
populations,
you
mentioned,
like
cancer
patients.
Elizabeth:
We’ll
look
forward
to
those
studies
and
hope
they
have
similar,
really
good
outcomes.
On
that
note
then,
that’s
a
look
at
this
week’s
medical
headlines
from
Texas
Tech.
I’m
Elizabeth
Tracey.
Rick:
And
I’m
Rick
Lange.
Y’all
listen
up
and
make
healthy
choices.
Please
enable
JavaScript
to
view
the