October 2020

Authors:

Dr Chris Connolly
Dr Becky Maxwell

Show notes:

This month Becky and Chris turn their eye on guidelines published in 2020 focussed on mental health in the ED. These guidelines and tool kit have been produced collaboratively with RCPsych, RCEM, RCP and the RCN.

Mental health presentations form a big part of our workload and we as EPs need to be on point with this. Our CPD needs to reflect our workload and we should all look to ensure we keep up to date on mental health topics as much as we do chest pain or sepsis!!

Mental health patients should have a mental health specific triage when they arrive in your ED, patients should be observed if medium or high risk and re-triage can occur at any point.

Patient capacity assessment and a description should form part of this triage process. Remember this can take some time so ensure your nurses are supported in doing this. You can hear Becky and Chris discussing Mental Health Act and capacity in Feb 2019 here (https://www.rcemlearning.co.uk/foamed/february-2019/)

If you have the system in place a patient with an isolated mental health problem and no physical health needs can be triaged directly to the mental health team. This may not suit every hospital/ED system so make sure you engage your local stakeholders if this is a potential path for your ED!

Areas of good practice recommended by the toolkit you should consider are using a mental health proforma and where possible use an accredited mental health room/cubicle for seeing patients. Double door access, surveyed and safe of ligature points etc. We are also encouraged not to use phrases such as ‘medically fit’ but ‘fit for assessment’, ‘fit for review’ or ‘fit for discharge’ in lieu of the vague former term.

Whilst Becky and Chris don’t routinely see children in their practice the guidelines serve a timely reminder of the importance of child safeguarding and how ownership of this is all of our responsibility!

References

www.rcpsych.ac.uk

www.rcem.ac.uk

Clinical Question

Should we be sending our Paeds gastro patients home with a script for ondansetron?

Title of Paper

Ondansetron Prescription Is Associated With Reduced Return Visits to the Pediatric Emergency Department for Children with Gastroenteritis

Journal and Year

Annals of Emergency Medicine. 2020.

Lead Author

Doreen Benary

Background

– I think everyone is pretty sold on using ondansetron for the ED treatment of paediatric vomiting / gastroenteritis
– Its been shown to reduce vomiting, facilitate oral hydration and decrease hospitalisation rates
– But should we be sending them home with a script for more?
– There are concerns that it could mask other causes of patient symptoms and lead to bad outcomes (CNS infection, appendicitis, Intussusception etc).

Study Design

– Retrospective cohort study
– Paediatric patient presenting to a large, urban, tertiary care paediatric ED and affiliated urgent care centres

Patients Studied

– Kids ages 6m to 18 years
– Discharge diagnosis of gastroenteritis, vomiting and diarrhoea, vomiting alone, gastritis, dehydration.

Methods

– Interrogated their health systems data warehouse
– Usual demographics and clinical info plus provision of home prescription for ondansetron; other home prescriptions ordered; 72 hour and 1 week returns

Outcome Measures:

– Primary: return rate at 72 hours
– Secondary:
– Return at 72 hours (just gastroenteritis)
– Association between ondansetron discharge script and alternate diagnosis on return visit (appendicitis, intussusception, intracranial mass, meningitis, DKA) within 7 days

Summary of Results

– 82,139 patients studied
– Further 5445 excluded from multivariate analysis due to incomplete data
– 59% presentation were to ED
– 22% seen by Paeds EM Physician
– 55% got ondansetron during their visit
– 8% got IV fluids
– 13.5% had some form of imaging
– 13.4% got discharge script for ondansetron
– Difference in baseline for most characteristics

Primary

– 4.7% had return within72 hours
– Ondansetron script deduced odds of return (unadjusted OR 0.84 (0.76-0.92)
– Adjusted OR 0.84 (0.75-0.93)

– Other covariates associated with increased likelihood to return:
– Younger age
– IV fluid bolus
– Treatment by Paeds EM Physician
– Treatment with ondansetron during index visit
– Radiological study during visit
– (Generally all things that would suggest increased severity of illness)

Secondary

– Gastroenteritis only:
– Similar results (OR 0.82 (0.72-0.95)
– Alternative dx:
– Appendicitis = 0.05% patients, no difference between groups
– Intussusception = 16 cases all in non-prescription group
– Meningitis = 2 cases, none-prescription group
– No intracranial masses, no DKA

Authors Conclusion

We found that receiving an ondansetron prescription is associated with reduced 72-hour visits for children with vomiting and gastroenteritis and is not associated with masking alternate diagnoses.

NNT 138 (because the baseline return rate was low (4.7%) making for small absolute difference.

– Despite the relatively high NNT, we consider our findings clinically significant, given the frequency with which patient with vomiting and gastroenteritis are treated in the ED and discharged home.

Prospective studies are needed to evaluate the direct effect of ondansetron prescription on return visits to the ED

Clinical Bottom Line

I do occasionally send paediatric patients home with an ondansetron script, on a case by case basis and sometimes on parent request. But have to admit Ive probably not done it frequently perhaps for the same reasons they outlined in the introduction, fear of masking something. Along with a lack of evidence to support that approach.

Ill probably change my tact a little based on this. Yes its retrospective data, and by no means is a definitive answer and yes, an NNT of 138 is high. But ondansetron is safe and this at least refutes the fear of masking something nasty theory.

Authors:

Dr Michelle Tipping
Dr Mark Winstanley