Washington University Emergency Medicine Knowledge Translation Project

Utilization of Corticosteroids in Bacterial Meningitis Bringing the Evidence to the Bedside

Objectives

• Knowledge Translation Review• Wash U EM KT Project Methods• Wash U EM KT Project Results

• KT gap identification • Retrospective chart review• Internal Survey• External Survey

What is Knowledge Translation?

1 2 3 4 5 6

0% 0% 0%100%0%0%

1. I have no idea

2. I don’t care

3. Behavioral science

4. Translating foreign manuscripts

5. The science of moving from evidence to action

6. Being made aware of evidence through Journal Club or CME

What Is Knowledge Translation?

• A dynamic process that includes synthesis, dissemination, exchange, and ethically sound application of knowledge to provide more effective health care services and products to strengthen the health care system

• Canadian Institutes of Health Research

• A structured process that results in scientifically researched evidence being used to improve the outcomes of professional practice

Traditional Journal Club formats are Knowledge Translation.

1 2 3

16% 0%84%1. Yes

2. No

3. Uncertain

3 Distinguishing Features

• Emphasizes the process of qualifying research evidence• Supports the flow of data and understanding from researcher to

practitioner or policy-maker (as well as the flow from practitioner and policy-maker to researcher)

• Pertains to complex social and organizational contexts

Why Is Knowledge Translation Important?

• The creation of new knowledge often does not on its own lead to widespread implementation or impacts on health

• One study, published in the New England Journal of Medicine, looking at 12 hospitals, >400 quality indicators and 6,700 patients, found that 45% of patients do not receive recommended care

• A significant amount of time is needed for scientific research to be incorporated into clinical practice (6-13 years)

Steps of Knowledge Translation

• Synthesis -- the contextualization and integration of research findings of individual research studies within the larger body of knowledge on the topic

• Must be reproducible and transparent in its methods, using quantitative and/or qualitative methods

• Systematic reviews, methods developed by the Cochrane Collaboration, results of a consensus conference or expert panel

• Realist syntheses, narrative syntheses, meta-analyses, meta-syntheses and practice guidelines

• Dissemination -- identifying the appropriate audience, and tailoring the message and medium to the audience

• Educational sessions with patients, practitioners and/or policy makers• Developing and executing the dissemination and implementation plan, tools

creation, and media engagement

Steps of Knowledge Translation

• Exchange – the interaction between the knowledge user and the researcher resulting in mutual learning

• Collaborative problem-solving between researchers and decision makers that happens through linkage and exchange, resulting in mutual learning through the process of planning, producing, disseminating, and applying existing or new research in decision-making

• Ethically sound -- must be consistent with ethical principles and norms, social values, as well as legal and other regulatory frameworks

• Keep in mind that principles, values and laws can compete among each other at any given point in time

• Application of knowledge -- the iterative process by which knowledge is put into practice

Knowledge Cycle

What Significant KT Gap was identified at BJH?

• The second-year class proposed that we were not following evidence-based guidelines regarding the utilization of adjunctive corticosteroids in the treatment of acute bacterial meningitis

• Other KT gaps considered:• Use of Plavix in ACS/STEMI• Utility of LP after negative head CT in SAH• Utilization of Canadian C-spine/Nexius criteria when ordering C-spine films• Need for pre-oxygenation in procedural sedation

• A retrospective chart review was performed to assemble objective evidence of this gap in Knowledge Translation

• All ED patient charts within a 1 year period (9/1/06 to 8/30/07) were examined for inclusion into the study

• All patients given the diagnosis of meningitis or encephalitis who underwent lumbar puncture were included

• Patients meeting SIRS criteria were excluded from the study

How many bacterial meningitis patients have you diagnosed over the last 12 months in the

ED?

1 2 3 4 5 6

53% 21% 11%0%5%11%1. None

2. 1

3. 2

4. 3

5. 4

6. > 5

I read all of tonight’s Journal Club articles.

1 2

89%11%1. Yes

2. No

In definite bacterial meningitis, medical evidence suggests a role for steroids.

1 2

6%94%1. Yes

2. No

The articles distributed for tonight changed my opinion about the use of steroids in meningitis.

1 2 3

0% 41%59%1. Yes, from “use” to

“don’t use”

2. Yes, from “don’t use” to “use”

3. No

In most patients I evaluate, I cannot clearly distinguish bacterial meningitis from other potential

sources of symptoms before CSF results are available.

1 2

0%100%1. Yes

2. No

Background on the Use of Steroids in Acute Bacterial Meningitis (ABM)

• Despite advances in vaccinations and antibiotic therapy, significant morbidity and mortality exists in patients with ABM

• There are approximately 25,000 cases of ABM yearly• Review of the literature demonstrates that administering

corticosteroids with antibiotics improves outcomes (especially in cases of Strep. pneumoniae)

• Inflammatory responses within the CNS are thought to cause increased morbidity and mortality in these patients

• Administration of dexamethasone (10 mg IV Q 6 hours) has shown clinical efficacy in reducing morbidity and mortality when given with (or prior to) appropriate antibiotic therapy

Inflammatory Cascade in ABM

Retrospective Review Data

• 65 patients had a diagnosis of meningitis or encephalitis• 2 were excluded for repeat visits• 4 were excluded because no LP was performed

• 15 of the remaining 59 patients met the gold standard criteria for the diagnosis of meningitis with a positive CSF culture

• 2 were positive for Strep. pneumoniae• 1 was positive for Strep. dysgalactiae• 1 was positive for coagulase-negative Staph.• 7 were positive for HSV• 1 was positive for enterovirus• 1 was positive for arbovirus• 2 were positive for Cryptococcus

Retrospective Review Data

• 8/59 patients received steroids (13.6%)• 4/8 received steroids before or at the time of antibiotic administration (6.8%)• 2/8 had positive CSF cultures (both with Strep. pneumoniae)

• Conclusion: Steroids are not given routinely prior to antibiotic administration for presumed meningitis despite current recommendations

How Large is the KT Gap at BJH?

• A survey was distributed to Wash U Emergency Medicine residents and attendings asking questions about the use of steroids in ABM in their clinical practice

• 76 of 88 (86.4%) responded

• 31 of 76 (40.8%) indicated routinely using steroids in suspected cases of meningitis in adults

• 45 of 76 (59.2%) do not routinely use steroids

• 35 of 74 (47.3%) indicated using steroids in suspected cases of meningitis in pediatric patients

• 39 of 74 (52.7%) do not use steroids in suspected cases of meningitis in pediatric patients

How Large is the KT Gap at BJH?

• 33/76 (43.4%) indicated that they administer steroids prior to antibiotic therapy

• 19/76 (25.5%) administer steroids with antibiotics• 7/76 (9.2%) administer steroids post-antibiotics• 21/76 (27.6%) do not use steroids at all

• In summary, less than half of the physicians surveyed routinely use steroids in cases of suspected ABM

• 88% of the physicians considering steroids as adjunctive therapy indicated that they would administer steroids prior to, or concurrent with, antibiotics

I almost always obtain a head CT before performing an LP.

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28%72%1. Yes

2. No

Surprise Finding!

• Pre-LP CT obtained in 100% of cases!

Literature Review

Knowledge Translation Pipeline

How Were Leaks in the Pipeline Identified at BJH?

• In order to identify specific leaks in the KT Pipeline, survey questions were designed to address hypothesized barriers in bringing the evidence to the bedside

• Responses were analyzed and categorized for each step in the KT Pipeline

Awareness

• Leaks in this leg of the Pipeline include:• Information overload• Literature search deficiency• Inadequate time• Insufficient strategies

• Proposed solutions:• Accessible appraisals• Automatic delivery of newsworthy, clinically relevant evidence

Awareness

• Are residents and attendings unaware of the large amount of research data supporting the use of corticosteroids as an effective adjunctive therapy for ABM?

• Yes = 13/74 (17.6%)• No = 61/74 (82.4%)

• I have never been taught that steroids were an important therapy in ABM

• Yes = 27/75 (36.0%)• No = 48/75 (64.0%)

• I have no idea what dose of steroids is appropriate• Yes = 34/76 (44.7%)• No = 42/76 (55.3%)

Awareness

• I have no idea when steroids should be administered in conjunction with antibiotics for ABM

• Yes = 21/76 (27.6%)• No = 55/76 (72.4%)

• Resources used to keep up-to-date on the latest EM literature• Wash U EM Journal Club (71.2%)• Wash U EM Lecture Series (54.5%)• EM Rap (30.3%)• EM Abstracts (25.8%)• EM Journal Watch (21.2%)• Audio Digest (19.7%)• Practical Reviews in EM (10.6%)• BEEM (1.5%)• Many others = Uptodate, eMedicine, NEJM, Annals, ACEP News, LLSA,

etc.

Acceptance

• Leaks in this leg of the Pipeline include:• Competing influences• Marketing• Authoritarian doctrine• Contradictory experience• Poorly-differentiated healthy vs. unhealthy skepticism

• Proposed solutions:• Tort reform• Interdisciplinary education• Balanced commercials

Acceptance

• Does current research data support the use of steroids in ABM?• Yes = 53/75 (70.7%)• No = 29/75 (29.3%)• 4 respondents stated that steroids were beneficial depending on the

organism involved• 2 respondents stated that steroids may be beneficial in patients with a

“high suspicion” of ABM• 5 respondents stated that current literature only supports using steroids in

pediatric patients with ABM• 3 respondents stated that the literature was “thin” or “conflicting,” or that

“the impact is limited”• 2 respondents were “unfamiliar” or “not clear” on the literature

Acceptance

• My physician peers doubt the efficacy of steroids in ABM• Yes = 35/69 (50.7%)• No = 34/69 (49.3%)

• My nursing peers doubt the efficacy of steroids in ABM• Yes = 22/69 (31.9%)• No = 47/69 (68.1%)

Applicable

• Leaks in this leg of the Pipeline include:• Uncertain interpretation• Uncertain local demographics• Clinically significant differences from study population

• Proposed solutions:• Increased pragmatic clinical trials• Clear description of demographics

Applicable

• Findings which would increase the likelihood to use steroids in suspected ABM:

• Abnormal CSF white count (88.6%)• Any combination of altered mental status, stiff neck, photophobia (79.1%)• Positive CSF gram stain (77.6%)• Abnormal CSF glucose (56.7%)• Altered mental status (56.7%)• Fever (55.2%)• Petechial rash (55.2%) • Stiff neck (49.3%)• Abnormal CSF protein (47.8%)• Headache (34.3%)• Elevated LP opening pressure (31.3%)

Able

• Leaks in this leg of the Pipeline include:• Resource constraints• Skill competence

• Proposed solutions:• Original research description of evidence use at dissimilar clinical settings

Able

• ABM often presents atypically, limiting my ability to recognize it as the source of presenting symptoms in time to permit administration of steroids before antibiotics

• Yes = 38/76 (50.0%)• No = 38/76 (50.0%)

Act On

• Leaks in this leg of the Pipeline include:• Hectic ED environment• Frequent distractions• Competing mandates

• Proposed solutions:• PDA or computer entry prompts

Act On

• Multiple other standards of care or quality measures are more important priorities

• Yes = 47/76 (61.8%)• No = 29/76 (38.2%)

• Steroid administration is not a QI measure and is therefore less important than other clinical performance measures

• Yes = 21/75 (28.0%)• No = 54/75 (72.0%)

• ED overcrowding precludes the timely recognition of ABM necessary to safely administer steroids

• Yes = 23/76 (30.3%)• No = 53/76 (69.7%)

Act On

• ED overcrowding reduces my confidence in my ability to recognize ABM and permit the safe administration of steroids

• Yes = 17/76 (22.4%)• No = 59/76 (77.6%)

• Remembering to order steroids in suspected ABM while caring for multiple other sick patients in the ED is impossible

• Yes = 4/76 (5.3%)• No = 72/76 (94.7%)

• No order set exists to facilitate steroid administration to suspected ABM patients

• Yes = 61/72 (84.7%)• No = 11/72 (15.3%)

Agree

• Leaks in this leg of the Pipeline include:• Information overload• Competing influences

• Proposed solutions:• Community EBM education• Anticipate couterarguments

Agree

• Lacking of an established statement listing steroids in ABM as standard of care (e.g. ACEP guideline), I fear increased malpractice risk if I use steroids for this indication

• Yes = 12/76 (15.8%)• No = 64/76 (84.2%)

Summary and Subgroup Analysis

• Though leaks in the pipeline were identified at each step, subgroup analysis of the two groups (steroid users vs. non-users) highlighted two areas in particular

• Awareness• Steroid users were more aware of supporting research, appropriate doses

and timing of steroids, and reported having been taught that steroids are beneficial in ABM when compared with non-users

• Acceptance• Steroid users reported less doubt within their physician and nursing peer

groups when compared with non-users

External Validation

• In order to assess whether or not this Knowledge Translation Gap exists in other institutions, a similar survey was sent out to a number of EM programs across the country, including both academic and community centers

• 35 of 65 (53.8%) responded and data analysis was performed

• 18 of 35 (51.4%) “almost always” give steroids to adult patients with suspected ABM

• Reasons for integrating steroids into the management pathway in ABM?• The supporting literature is indisputable (73.7%)

• My clinical instructors taught me that steroids are standard of care (42.1%)

• 17 of 35 (48.6%) do not “almost always” give steroids

What Explanations Were Given as to Why Steroids are not Routinely Used in ABM?

• Awareness• I am unaware of the correct dose of steroids = 35.7%• Unaware of evidence supporting use of steroids in ABM = 14.3%

• Acceptance• Research evidence is inconclusive = 42.9%

• Able• Diagnostic delays impede the timely administration of steroids in ABM =

14.3%

• Act On• I simply forget to administer steroids in the rare ABM patient = 35.7%• Steroids are not part of my hospital’s meningitis treatment algorithm or

standardized orders = 21.4%

What Solutions Were Proposed by Outside Institutions to Fix These Leaks in the Pipeline?

• Awareness• Journal Club = 82.4%• Didactic programs within the institution = 35.3%

• Act On• Order sets within the ED = 5.9%

• Adhere• Quality Improvement teams review performance = 17.6%

• Individual responders noted that their awareness came from:• Attendings distributing articles• LLSA (ABEM article)• BEEM

What Barriers Were Encountered While Incorporating the Use of Steroids in ABM?

• In the hectic ED environment, I simply forget to administer steroids in ABM (55.6%)

• Difficulty distinguishing between viral and bacterial meningitis before LP (50.0%)

• Delays in diagnosis CNS infection (38.9%)• Concerns about steroid-related adverse effects (27.8%)• Uncertainty about the timing of steroids relative to antibiotics and

CSF results (27.8%)• Difficulty distinguishing viral from bacterial meningitis after the LP

(16.7%)• Consult services disagreed with steroids in ABM (16.7%)• Skepticism from my EM colleagues (11.1%)• Inability to understand the evidence supporting this therapy

(5.6%)

Conclusions

• Wash U EM does not differ significantly from our national sampling for• Awareness of supporting literature (14% vs 18%

unaware)• Timing of steroids relative to antibiotics (28% in both

groups unaware)

Conclusions, continued

• BJH physicians were more likely to accept the supporting literature (29% BJH vs. 43% outside institutions felt data inadequate), but less likely to be using steroids in meningitis (41% BJH vs. 51% outside institutions currently using steroids in suspected adult meningitis)

• Dosing at BJH often inappropriate• 26% with antibiotics• 9% after antibiotics

Conclusions

• Potential “faucets” for the largest leaks include• Tonight’s literature review (Awareness/Acceptance)• Steroids into meningitis order set (Able/Act On)• Frequent reminders of steroids in meningitis via

• Didactics• LLSA• QI reviews• Incorporation into the standard of care

• Textbooks• Narrative reviews• Medical student/GME educational models

The Biggest Hurdle

• Atypical disease presentation and delayed diagnoses• Delayed antimicrobials increase bacterial meningitis

related morbidity and mortality• Viral and bacterial CNS infections present with similar

signs/symptoms• CSF findings available in the ED cannot reliably

distinguish viral and bacterial meningitis• Steroids may be harmful to non-bacterial CNS

infections such as TB, HIV, and HSV encephalitis

My Recommendation

• Steroids should be administered 15-minutes prior to antibiotics if• Positive CSF gram stain• Clear petechiae rash in conjunction with fever,

headache, or altered mental status• Purulent CSF• CSF WBC > 1000 cells/mm3

• High clinical suspicion of bacterial meningitis

A “Knowledge Translation” Journal Club such as we’ve discussed tonight is superior to our

typical JC.

1 2 3

90% 5%5%1. Yes

2. No

3. Uncertain

I would like to have another Knowledge Translation project next year.

1 2

5%95%1. Yes

2. No

Tonight’s discussion changed my opinion about the use of steroids in meningitis.

1 2 3

14% 52%33%1. Yes, from “use” to

“don’t use”

2. Yes, from “don’t use” to “use”

3. No

Washington University’s EM program should purchase the Turning Point system for routine

use in our lectures and Journal Club

1 2

0%100%1. Yes

2. No

Future Directions

• Following this Journal Club, we will analyze management of potential meningitis cases presenting to the ED

• Annual Knowledge Translation projects would continue to help shorten the lag time needed to bring high quality evidence into clinical practice by identifying pertinent leaks in the KT Pipeline