Boarding in the ED; Devices or Manual CPR?

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.