Inpatient utilization of blood cultures drawn in an urban ED.

Bloodstream infections are now ranked as the 10th leading cause of death in the United States. Given the severity of bacteremia, physicians routinely order multiple sets of blood cultures in the emergency department. This is a retrospective chart review on 1124 patients admitted to the hospital for suspected bacteremia during calendar year 2004. The aims of the present investigation were to investigate the overall utility of blood cultures by the admitting services and to identify patient factors that might influence culture yield. Data were collected regarding patient demographics, comorbidities, vital signs, laboratory results, antibiotic use, blood culture results, and notation of blood culture results by admitting physicians. Increased age, elevated heart rate, use of chemotherapy, decreased sodium, and increased blood urea nitrogen significantly increased the likelihood of yielding a positive blood culture in our patient population. Culture results were noted in 517 patient charts by the primary medical team (46.0%) and were adjusted in 223 patients (43.3%). Of 1124 cultures, 10.3% were positive in at least 1 bottle for a pathogenic organism (true positive), and 6.3% were contaminants (false positive). In conclusion, cultures must be followed closely by the admitting physician after being obtained. Our data emphasize that blood cultures are currently not well used by the admitting physicians and that measures need to be taken to improve the overall utility of blood culture data by the admitting physician.

Optic nerve ultrasound for the detection of elevated intracranial pressure in the hypertensive patient.

PURPOSE: We sought to determine whether dilation of the optic nerve sheath diameter (ONSD), as detected at the bedside by emergency ultrasound (US), could reliably correlate with patient blood pressure and whether there was a blood pressure cutoff point where you would start to see abnormal dilation in the ONSD. METHODS: This was a single-blinded, prospective, observational trial from September 2010 to April 2011. One hundred fifty patients presenting to the emergency department were enrolled. There were 3 arms to the study with 50 patients in each arm: (1) ONSD in normotensive/asymptomatic patients; (2) ONSD in hypertensive/asymptomatic patients; and (3) ONSD in hypertensive/symptomatic patients. Ocular US was conducted on all subjects. RESULTS: Neither the number of symptoms nor the type of symptom present in the hypertensive/symptomatic group was able to significantly predict the average ONSD before treatment (P = .818 and .288, respectively). There was a significant correlation between both systolic blood pressure (SBP) and diastolic blood pressure (DBP) with the ONSD in all hypertensive patients. The best SBP and DBP cutoff point for abnormal ONSD was 166/82 mm Hg. Decrease in ONSD observed after blood pressure treatment was not statistically significant (P = .073). CONCLUSIONS: In conclusion, our study shows that practitioners can use bedside ocular US and a blood pressure cutoff point to help predict whether patients require more aggressive management of their symptomatic hypertension. Knowing the SBP and DBP readings that lead to increased ONSD and increased intracranial pressure can help guide management and treatment decisions at the bedside.