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Volume 18, Issue 3, 2017
Table of Contents
Discourse on Integrating Emergency Care and Population Health
Not applicable (Letter to the Editor)
Treatment Protocol Assessment
Introduction:A subpopulation of sickle-cell disease patients, termed super-utilizers, present frequently to emergency departments (EDs) for vaso-occlusive events and may consume disproportionate resources without broader health benefit. To address the health care needs of this vulnerable patient population, we piloted a multidisciplinary intervention seeking to create and use individualized patient care plans that to alter utilization through coordinated care. Our goals were to assess feasibility primarily, and to assess resource use secondarily.
Methods: We evaluated the effects of a single-site interventional study targeted at a population of adult sickle-cell disease super-utilizers using a pre- and post-implementation design. The pre-intervention period was 06/01/13 to 12/31/13 (7 months) and the post-intervention period was 01/01/14 to 02/28/15 (14 months). Our approach included: patient-specific best practice advisories (BPA); an ED management protocol (figure 1); formation of a "medical home" for these patients.
Results: For 10 subjects targeted initially we developed and implemented coordinated care plans; after deployment, we observed a tendency toward reduction in ED and inpatient utilization across all measured indices. Between the annualized pre- and post-implementation periods: ED visits decreased by 16.5 visits/pt-yr (95% CI, -1.32 to 34.2); ED length of state (LOS) decreased by 115.3 hours/pt-yr (95% CI, -82.9 to 313.5); in-patient admissions decreased by 4.20 admissions/pt-yr (95% CI, -1.73 to 10.1); in-patient LOS decreased by 35.8 hours/pt-yr (95% CI, -74.9 to 146.7); and visits where the patient left before treatment was reduced by an annualized total of 13.7 visits. We observed no patient mortality in our 10 subjects and no patient required admission to the ICU care 72 hours following discharge.Conclusion: This effort suggests that a targeted approach is both feasible and potentially effective, laying a foundation for broader study.
Study Objective: The purpose of this study was to evaluate and categorize current state-sponsored opioid guidelines which affect Emergency Medicine practice.
Methods: We conducted a comprehensive search of emergency medicine-specific opioid prescribing guidelines and/or policies in each state to determine current state involvement in emergency medicine opioid prescribing, as well as to evaluate some of the specifics of each guideline or policy. The search was conducted using an online query and a follow-up email request to each state chapter of ACEP.
Results: We found that eighteen states had emergency department-specific guidelines. We further organized these into four categories; Limiting Prescriptions for Opioids with 67 total recommendations, Preventing/Diverting Abuse with 56 total recommendations, Addiction related guidelines with 29 total recommendations, and a Community Resources section with 24 total recommendations. Our results showed that current state guidelines focus on providers limiting opioid pain prescriptions and vetting patients for possible abuse/diversion..Conclusion: This study highlights the 18 states that have addressed opioid prescribing guidelines and categorizes their efforts to date. It is hoped that this work will provide the basis for similar efforts in other states.
Injury Prevention and Population Health
Introduction. Survey data regarding the prevalence of risky substance use in the emergency department (ED) is not consistent. The objective of this study is to identify the prevalence of risky substance use among injured ED patients based on the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST v3.0). A secondary objective was to report on the feasibility of administering the ASSIST to this population, based on the time to conduct screening. Methods. This cross-sectional study used screening data from a randomized controlled trial. Injured ED patients completed the ASSIST on a tablet computer, and an ASSIST score was computed that indicated the need for a brief or intensive treatment intervention (risky use) for alcohol and other substances. For a subsample, data to complete each step of screening was recorded. Results. Between July 2010 and March 2013, 5,695 patients completed the ASSIST. Most (92%) reported lifetime use of at least one substance and 51% reported current risky use of at least one substance. Mean time to complete the ASSIST was 5.4 minutes and screening was feasible even when paused for clinical care to proceed. Conclusion. Estimates of risky substance use based on the ASSIST in our large sample of injured ED patients are higher than previously reported in other studies of ED patients, possibly due to the current focus on an injured population. In addition, it was feasible to administer the ASSIST to patients in the course of their clinical care.
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Disaster Medicine/ Emergency Medical Services
Introduction. The purpose of this multicenter, prospective study was to assess differences in demographics, medical history, treatment times, and follow-up status among patients with ST-elevation myocardial infarction (STEMI), who were transported to the hospital by emergency medical services (EMS), privately, or transferred from other medical facilities.
Methods. Our sample consisted of 455 patients admitted to 4 hospitals in “blinded for peer review.” We collected electronic medical records from EMS and hospitals, and conducted interviews with patients in-person or via telephone. Chi-square tests and Kruskal–Wallis tests were used to examine differences in variables by mode of transportation.
Results. Results indicated significant differences in modes of transportation when considering symptom-onset-to-balloon-time (p < 0.001), door-to-balloon time (p < 0.001), and health status at 6-month and 1-year follow-up (p < 0.001). In all cases, EMS transportation was associated with a shorter time to treatment than other modes of transportation. However, the EMS group experienced greater rates of in-hospital events, including cardiac arrest and mortality, than the private transport group.
Conclusion. Our results contribute data supporting EMS transportation for patients with acute coronary syndrome. Although a lack of follow-up data made it difficult to draw conclusions about long-term outcomes, our findings clearly indicate that EMS transportation can speed time to treatment, including time to balloon inflation, potentially reducing readmission and adverse events. We conclude that future efforts should focus on encouraging the use of EMS and improving transfer practices. Such efforts could improve outcomes for patients presenting with STEMI.
Societal Impact on Emergency Care
Impact of Health Policy Changes on Emergency Medicine in Maryland Stratified by Socioeconomic Status
Introduction On January 1, 2014, the financing and delivery of healthcare in the state of Maryland (MD) profoundly changed. The insurance provisions of the Patient Protection and Affordable Care Act (ACA) began implementation and a major revision of MD’s Medicare Waiver ushered in global budget revenue (GBR) structure for hospital reimbursement. Our objective is to analyze the impact of these policy changes on Emergency Department (ED) utilization, admission practices, insurance profiles, and professional revenue. We stratified our analysis by the socioeconomic status (SES) of the ED patient population.
Methods Monthly mean data including patient volume, admission and observation percentages, payer mix, and professional revenue were collected from January 2013 through December 2015 from a convenience sample of 11 EDs in Maryland. Using regression models, we compared each of the variables 18 months after the policy changes and a six-month washout period to the year prior to ACA/GBR implementation. We included the median income of each ED’s patient population as an explanatory variable and stratified our results by SES.
Results Our 11 EDs saw an annualized volume of 399,310 patient visits during the study period. This ranged from a mean of 41 daily visits in the lowest volume rural ED to 171 in the highest volume suburban ED. After ACA/GBR, ED volumes were unchanged (95% Confidence Interval (CI): (-1.58, 1.24), p=.817). Admission plus observation percentages decreased significantly by 1.9% from 17.2% to 15.3% (95% CI: (-2.47%, - 1.38%), p<.001). The percentage of uninsured patients decreased from 20.4% to 11.9%. This 8.5% change was significant (95% CI: (-9.20%, -7.80%), p<.001). The professional revenue per relative value unit increased significantly by $3.97 (95% CI: (3.20, 4.74), p<.001). When stratified by the median patient income of each ED, changes in each outcome were significantly more pronounced in EDs of lower SES.
Conclusion Health policy changes at the federal and state levels have resulted in significant changes to emergency medicine practice and finances in MD. Admission and observation percentages have been reduced, fewer patients are uninsured, and professional revenue has increased. All changes are significantly more pronounced in EDs with patients of lower SES.
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Emergency Department Access
Background/Objective: To determine the prevalence of homelessness or at-risk for homelessness in the ED setting.
Methods: Using a 5 question screening tool derived from teh US department of Housing and Urband Development (HUD), Health and Human Services (HHS) and the Beterans Administration (VA) definition for homelessness, we surveyed all patients meeting inclusion criteria on scheudled shifts in one of three EDs in Northeastern Pennsylvania Two survey periods were selected to represent seasonal variations.
Results: 4395 subjects were included in the analysis. The mean age of participants was 50.8 (SD 20.5) and 2,557(58.2%) were women. The mean age of those who screened positive for homelessness or at-risk for homelessness was 43.1 (SD16.6). Overall, 136 (3.1%) participants screened positive for at-risk for homelessness and 309 (7.0%) screened positive for homelessness. 103 (9.8%) subjects screened positive for homelessness or at-risk for homelessness on weekends and 312 (10.3%) on weekedays (p=-.64). The proportion of those screening positive for homelessness or at-risk for homelessness varied by site: 145 (7.5%) at hte trauma cetner, 151 (9.1%) at the suburban site and 149 (18.7%) at the center city site, p<0.001. There was no statistical significance to the difference between the trauma center and the suburban site (p=.088), but there was statistical significance between both the suburban and the trauma cneter when compared to the center city site (both p<0.0001). The proportion of those screening positive for homelessness in the summer months (156,7.5%) was similar to those in the winter months (153, 6.6%), p=-.23, but it did favor summer months if those who were at-risk for homelessness were included (230, 11.1%, summer versus 215, 9.2% winter; p=0.045).
Conclusions: In our study, the overall prevalence of homelessness or at-risk for homelessness was 10.1%. This prevalence did not seem to vary between weekdays and weekends. Additionally summer months had a prevalence that was was concerning as winter months. The prevalence does, however, seem to vary by institutional characteristics even in the same geographic region. Understanding the patterns of prevalence of homelessness is a step toward considering possible interventions to assist this vulnerable population
Randomized Trial of Adding Parenteral Acetaminophen to Prochlorperazine and Diphenhydramine to Treat Headache in the Emergency Department
Introduction: Headaches represent over 3 million Emergency Department visits per year comprising 2.4 percent of all ED visits. Headaches are thought to be one of the three most common complaints of patient presentations to EDs across the country. There are many proposed methods and clinical guidelines of treating acute headache presentations however data on intravenous acetaminophen usage in these settings are lacking.
Objectives: The study attempts to determine the efficacy of IV Acetaminophen as an adjunct to a standard therapy for the treatment of patients who present to the emergency department with a chief complaint of “headache” or variants thereof.
Design: Randomized, double-blind, placebo-controlled trial. Institutional IRB approval was obtained prior to implementation.
Setting: Academic Community Hospital.
Patients: Key elements of eligibility included adults ages 18-65 who had no mental or physical hindrances to pain assessment or to receiving acetaminophen. Exclusion criteria included those who had received total cumulative dose of acetaminophen >2600mg within past 24 hours, documented or suspected pregnancy, dementia, psychosis, liver cirrhosis, hemodynamic instability or other medical conditions prohibiting acetaminophen use. Ability to understand informed consent was necessary.
Interventions: All patients received prochlorperazine, diphenhydramine, 1000ml 0.9% normal saline IV, and were randomized to receive either parenteral acetaminophen (1000mg/100ml) or 100ml of 0.9% NS as control in the placebo group.
Main outcome measures: Subjective pain scores rated on a 1-10 Visual Assessment Scale were assessed repeatedly at 30 minute intervals. Length of stay and time to disposition were also noted. The incidence of rescue medications required outside of the initial regimen was also noted, with particular attention to narcotic utilization.
Results: Of the (n=45) patients who received IV acetaminophen, 36 reported a statistically significant decrease by pain score of 2 or greater from presentation at the 90 minute mark. Of the (n=45) patients who received placebo, 25 reported a statistically significant decrease by pain score reporting from presentation at the 90 minute mark. (p 0.01, >95% CI). For the acetaminophen group the initial mean VAS pain score was 8.7, for the placebo group 8.6. At 90 minutes 2.2 for Acetaminophen, 4.0 for placebo group. (p<0.01, >99% CI). Length of stay was decreased a mean 36.6 minutes in the Acetaminophen group. 17 patients in the IV acetaminophen and 24 patients in the placebo group received rescue medications, with 18% less in the acetaminophen group requiring narcotics (p 0.01, CI >95).
Conclusion: In Emergency Department patients with acute headache, IV Acetaminophen when used as an adjunct to prochlorperazine and diphenhydramine resulted in increased pain reduction, decreased length of stay and less rescue medications utilized including narcotics when compared to treatment with prochlorperazine and diphenhydramine alone.
Clinician-Performed Bedside Ultrasound in Improving Diagnostic Accuracy in Patients Presenting to the Emergency Department with Acute Dyspnea
Diagnosing acute dyspnea is a critical action performed by Emergency Department (ED) physicians. It has been shown that ultrasound (US) can be incorporated into the work-up of the dyspneic patient; but there is little data demonstrating its effect on decision-making. Objectives: 1) To examine the impact of a bedside, clinician-performed cardiopulmonary US protocol on the clinical impression of ED physicians evaluating dyspneic patients; and 2) to measure the change in probability of the leading diagnosis before and after US. Methods: Prospective observational study of ED physicians treating adult patients with undifferentiated dyspnea in an urban academic center. Exclusion: known cause of dyspnea after evaluation. Outcomes: 1) percentage of post-US diagnosis matching final diagnosis; 2) percentage of time US changed providers’ leading diagnosis; and 3) change in providers’ confidence with the leading diagnosis before and after US. An US protocol was developed and standardized prior to the study. Providers (senior residents, fellows, attendings) were trained on US (didactics, hands-on) prior to enrollment, and were supervised by an US faculty member. After patient evaluation, providers listed likely diagnoses, documenting the probability of their leading diagnosis (scale of 1-10). After US, providers revised their lists and probabilities. Proportions are reported as percentages with 95%CI and continuous variables as medians with quartiles. The Wilcoxon rank-signed test and Cohen’s Kappa statistics were used to analyze data. Results: 115 patients were enrolled (median age: 61 [51, 73], 59% female). The most common diagnosis before US was CHF (41%, 95%CI, 32-50%), followed by COPD and asthma. CHF remained the most common diagnosis after US (46%, 95%CI, 38-55); COPD became less common (pre-US, 22%, 95%CI, 15-30%; post-US, 17%, 95%CI, 11-24%). Post-US clinical diagnosis matched the final diagnosis 63% of the time (95%CI, 53-70%), compared to 69% pre-US (95%CI, 60-76%). Fifty percent of providers changed their leading diagnosis after US (95%CI, 41-59%). Overall confidence of providers’ leading diagnosis increased after US (7 [6, 8]) vs. 9 [8, 9], p: 0.001). Conclusions: Bedside US did not improve the diagnostic accuracy in physicians treating ED patients presenting with acute undifferentiated dyspnea. US, however, did improve providers’ confidence with their leading diagnosis.
Introduction: Sexually transmitted infections (STIs) are a common reason for Emergency Department (ED) visits. The objective of this study was to see if there were gender differences in CDC diagnosis and treatment guidelines as documented by emergency physicians.
Methods: A retrospective chart review was performed to idenitfy patients treate for urethritis, cervicitis, and PID in the EDs of three hospitals in a PA network during a calendar year. Cases were reviewed to assess for compliance in documentation with CDC guidelines. Descriptive statistics were used to assess the distributions of study variables by patient sex. Student t-tess, chi-square tests, and logistic regression were used in the analysis. Statistical significance was set at p less than or equal to 0.05.
Results: 286 patient records were identified, of these 39 were excluded due to incorrect disease coding, the patient was admitted and treated as an inpatient for their disease, or the patient left the emergency department after refusing care. Of the 247 participangs, 159 (64.4%) were female. Females were significantly younger (26.6 years, SD=8.0) than males (31.2, SD=11.5%), (95%CI:2.0-7.0, p=0.0003). All of the males (n=88) in the cohort presented with urethritis;25.8% of females presented with cervicitis and 75.2% with PID. Compliance with documentation for the 5 CDC criteria ranged from 68.8% for patient history to 93.5% for patient diagnostic testing including urine pregnancy, and gonorrhea/chlamydia cultures. Significant differences were obesrved by patient sex. 54% of the charts had symptoms recorded for female patients that were consistent with CDC characteristics for diagnostic critera compared to over 95% for males , (OR=16.9, 95% CI 5.9-48.4, p less than 0.001). Similar results were observed for patient discharge instructions, with physicians completely documenting deliver of discharge instructions to 51.6% females compared to 97.7% of complet documentation in males OR=42.3;95%CI;10.0-178.6, p <0.001). No significant sex differences in documentaion were observed for exam or fo therapeutic antibiotic treatment. Conclusion: This retrospective study found patient gender differences in documentaiton compliance with CDC guidelines for the diagnosis and treatment of urethritis, cervicitis and PID
The objectives of this study were to determine the prevalence of fever in adult ED patients with skin and soft tissue infections (SSTI) and to determine which, if any, physical exam, x-ray and laboratory test findings were associated with fever.
We conducted a prospective, observational study at an urban county trauma center of adults who presented to the ED for evaluation of suspected SSTI. ED providers measured area of erythema and induration using a tape measure, and completed data sheets indicating comorbid conditions and the presence or absence of physical exam findings. Fever was defined as any recorded temperature > 38°C during the first 6 hours of ED evaluation.
Of the 734 patients enrolled, 96 (13.1%) had fever. Physical and laboratory exam findings associated with the presence of a fever in multivariable logistic regression were the area of erythema, particularly the largest quartile of area of erythema, 144 – 5000 cm2, (odd ratio (OR) = 2.9; 95% confidence interval [CI] = 1.6 – 5.2) and leukocytosis (OR = 4.4, 95% CI = 2.7 – 7.0). Bullae, necrosis, streaks, adenopathy, and bone involvement on imaging were not associated with fever.
Fever is uncommon in patients presenting to the ED for evaluation of suspected SSTI. Area of erythema and leukocytosis were associated with fever and should be considered in future decision rules for the evaluation and treatment of SSTI.
Emergency Department Operations
Background: Point-of-care (POC) testing allows for more time-sensitive diagnosis and treatment in the ED than sending blood samples to the hospital central laboratory (CL). However, many ED patients have blood sent to both, either out of clinical custom, or because clinicians do not trust the POC values.
Objective: To examine the level of agreement between POC and CL values in a large cohort of ED patients.
Methods: In an urban, Level One ED that sees approximately 120,000 patients/year, all patients seen between March 1st, 2013 and October 1st, 2014 who had blood sent to POC and CL labs had levels of agreement measured between serum sodium, potassium, BUN, creatinine, and hematocrit. Data were extracted from the hospital's clinical information system. Agreement was analyzed with the use of Bland-Altman plots, defining both 95% confidence intervals (CIs) and more conservative CIs based on clinical judgment.
Results: Out of 163,661 patients seen during the study period, 14,567 had blood samples sent both for POC and CL analysis. Using clinical criteria, the levels of agreement for sodium were 98.6% (within 5mg/dL), for potassium 90.7% (0.5 mmol/L), for BUN 89.0% (within 5 mg/dL), for creatinine 94.5% (within 0.3 mg/dL), for hematocrit 96.5% (within 5 g/dL).
Conclusion: Agreement between POC and CL values is excellent. Restricting the analysis to clinically important levels of agreement continues to show excellent agreement. The data suggest that sending a serum sample to the hospital CL for duplicate assays is unnecessary. This may result in substantial savings and shorter ED lengths of stay.
Emergency Department (ED) crowding is prevalent and can result in care delays, medical errors, increased costs and mortality. Simultaneously, capacity constraints on EDs are worsening, yet patient arrival rates and inpatient bed capacity are often outside the influence of ED administrators. Therefore systems engineering to improve throughput and reduce waste and waits holds the most readily available promise. Decreasing radiology turnaround times improves ED patient throughput and decreases patient waiting time. We sought to investigate the impact of systems engineering science targeting ED radiology transport delays, and determine the most effective techniques.
This prospective, before and after analysis of radiology process flow improvements in a academic hospital ED was exempt from Institutional Review Board review as a quality improvement initiative. We hypothesized that reorganization of radiology transport would improve radiology cycle time and reduce waste. The intervention included systems engineering science-based reorganization of ED radiology transport processes, largely utilizing Lean methodologies, and adding no resources. The primary outcome was average transport time between study order and complete time. All patients presenting between 8/2013-3/2016 and requiring plain film imaging were included. Electronic medical record data were analyzed using Microsoft Excel and SAS version 9.4.
Following the intervention, average transport time decreased significantly and sustainably. Average radiology transport time was 28.1 ± 4.2 minutes during the 3 months pre-intervention. It was reduced by 13% in the first three months (3.8 minutes; to 24.3 ± 3.3 min, P=0.021), 17% in the following six months (4.8 minutes; to 23.3 ± 3.5 min, P=0.003), and 24% one year following the intervention (6.8 minutes; to 21.3 ± 3.1 min, P=0.0001). This result was achieved without any additional resources, and demonstrated a continual trend towards improvement. This innovation demonstrates the value of systems engineering science to increase efficiency in Emergency Department (ED) radiology processes.
In this study, reorganization of the ED radiology transport process using systems engineering science significantly increased process efficiency without additional resource use.
Prehospital Care for the Adult and Pediatric Seizure Patient: Current Evidence Based Recommendations
Introduction: We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of adult and pediatric patients with a seizure and to compare these recommendations against the current protocol utilized by the 33 EMS agencies in California.
Methods: We performed a review of the evidence in the prehospital treatment of a patients with a seizure. We compared the seizure protocols of each of the 33 EMS agencies for consistency with these recommendations. We analyzed the type and route of medication administered, number of additional rescue doses permitted, and requirements for glucose testing prior to medication. The treatment for eclampsia and seizures in pediatric patients were analyzed separately.
Results: Protocols across EMS Agencies in California varied widely. Multiple drugs, dosages, routes of administration, re-dosing instructions, and requirement for blood glucose testing prior to medication delivery were identified. Blood glucose testing prior to benzodiazepine administratin is required by 61% (20/33) of agencies for adult patients and 76% (25/33) for pediatric patients. All agencies have protocols for giving intramuscular benzodiazepines and 76% (25/33) have protocols for intranasal benzodiazepines. Intramuscular midazolam dosages ranged from 2 to 10 mg per single adult dose, 2 to 8 mg per single pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intranasal midazolam dosages ranged from 2 to 10 mg pr single adult or pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intravenous/intrasosseous midazolam dosages ranged from 1 to 6 mg per single adult dose, 1 to 5 mg per single pediatric dose, and 0.05 to 0.1 mg/kg as a weight-based dose. Eclampsia is specifically addressed by 85% (28/33) of agencies. Forty-two percent (14/33) have a protocol for adminstering magnesium sulfate, with intravenous dosages ranging from 2 to 6 mg, and 58% (19/33) allow benzodiazepines to be administered.
Conclusion: Protocols for a patient with a seizure, including eclampsia, and febrile seizures, vary widely across California. These recommendations for the prehospital diagnosis and treatment of seizures may be useful for EMS Medical Directors tasked with creating and revising these protocols.
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Introduction: High quality CPR is critical for successful cardiac arrest outcomes. Mechanical devices may improve CPR quality. We simulated a prehospital cardiac arrest, including patient transport, and compared the performance of the LUCAS Chest Compression System to manual CPR. We hypothesized that because of the movement involved in transporting the patient, LUCAS would provide chest compressions more consistent with high quality CPR guidelines.
Methods: We performed a crossover controlled study in which a recording mannequin was placed on the second floor of a building. An EMS crew responded, defibrillated, and provided either manual or LUCAS CPR. The team transported the mannequin through hallways and down stairs to an ambulance and drove to the hospital with CPR in progress. Critical events were manually timed while the mannequin recorded data on compressions.
Results: Twenty-three EMS providers participated. Median time to defibrillation was not different for LUCAS compared to manual CPR (p=0.97). LUCAS had a lower median number of compressions per minute (p<0.002), which was more consistent with current American Heart Association CPR guidelines, and percent adequate compression rate (p<0.002). In addition, LUCAS had a higher percent adequate depth (p<0.007) lower percent total hands off time (p<0.005). LUCAS performed no differently than manual CPR in median compression release depth, percent fully released compressions, median time hands off, or percent correct hand position.
Conclusion: In our simulation, LUCAS had a higher rate of adequate compressions and decreased total hands off time as compared to manual CPR. Chest compression quality may be better when using a mechanical device during patient movement in prehospital cardiac arrest patients.
Areas of Potential Impact of the Patient Protection and Affordable Care Act on EMS: A Synthesis of the Literature
This comprehensive review synthesizes the existing literature on the Patient Protection and Affordable Care Act’s (ACA) as it relates to Emergency Medical Services (EMS) in order to provide guidance for navigating current and future healthcare changes. Patient usage and access to care, healthcare quality assessments, reimbursement changes, new EMS innovations, and changes to emergency preparedness are the major areas impacted by the ACA. Many changes enacted by the ACA directly affect emergency care with potential indirect effects on EMS systems. New Medicaid enrollees and changes to existing coverage plans may alter EMS transport volumes. Reimbursement changes such as adjustments to the Ambulance Inflation Factor (AIF) alter the yearly increases in EMS reimbursement by incorporating the multifactor productivity value into yearly reimbursement adjustments. New initiatives, funded by the Center for Medicare & Medicaid Innovation (CMMI) are exploring novel and cost effective prehospital care delivery opportunities while EMS agencies individually explore partnerships with healthcare systems.
Choosing Wisely Imaging Recommendations: Initial Implementation in New England Emergency Departments
In June 2016, the American College of Emergency Physicians (ACEP) Emergency Quality Network began its Reduce Avoidable Imaging Initiative, designed to “reduce testing and imaging with low risk patients through the implementation of Choosing Wisely recommendations”. However, it is unknown whether New England Emergency Departments (EDs) have already implemented evidence-based interventions to improve adherence to ACEP Choosing Wisely recommendations related to imaging after their initial release in 2013. Our objective was to determine this, as well as whether provider-specific audit-and-feedback for imaging had been implemented in these EDs.
This survey study was exempt from Institutional Review Board review. In 2015, we mailed surveys to 195 hospital-affiliated EDs in all six New England states to determine whether they had implemented Choosing Wisely-focused interventions in 2014. Initial mailings included cover letters denoting the endorsement of each state’s ACEP chapter, and were followed-up twice with repeat mailings to non-responders. Data analysis included descriptive statistics and a comparison of state differences using Fisher’s exact test.
A total of 169/195 (87%) of New England EDs responded, with all individual state response rates >80%. Overall, 101 (60%) of responding EDs had implemented an intervention for at least one Choosing Wisely imaging scenario; 57% reported implementing a specific guideline/policy/clinical pathway, 40% had implemented provider-specific audit-and-feedback, and 28% reported implementing a computerized decision support system. The most common interventions were for chest CT in patients at low-risk of pulmonary embolism (47% of EDs) and head CT in patients with minor trauma (45% of EDs). In addition, 40% of EDs had implemented provider-specific audit-and-feedback, without significant interstate variation (range: 29-55%).
One year after release of the ACEP Choosing Wisely recommendations, most New England EDs had a guideline/policy/clinical pathway related to at least one of the recommendations. However, only a minority were using provider-specific audit-and-feedback or computerized decision support. Few EDs have embraced the opportunity to implement the multiple evidence-based interventions likely to advance the national goals of improving patient-centered and resource-efficient care.
Introduction: Suboptimal communication during Emergency Department care transitions has been shown to contribute to medical errors, sometimes resulting in patient injury and litigation. The study objective was to determine whether a standardized checkout process would decrease the number of relevant missed clinical items (MCI).
Methods: In this prospective pre- and post-intervention study conducted in an urban academic ED, data on omitted or inaccurately conveyed medical information was collected before and after the initiation of a standardized checkout process. The intervention included group checkout in an optimal location, review of electronic medical records, case discussion and assigned roles. MCI were considered relevant if they resulted in a delay or alteration in disposition or treatment plan. The primary outcome was the change in the number of MCI. Secondary outcomes were duration of checkout and physician satisfaction with the intervention.
Results: Pre-intervention, there were 94 relevant MCI during 164 care transitions. Post-intervention, there were 36 MCI in 157 transitions. The mean MCI per transition decreased by 58% from 0.57 (95% CI 0.41, 0.73) to 0.23 (95% CI 0.11, 0.35). Instituting the intervention did not lengthen checkout duration, which was 15 minutes (95% CI 13.81, 16.19) pre-intervention and 14 minutes (95% CI 12.99, 15.01) post-intervention. The majority of participants (73.4%) felt that the process decreased MCI, and 89.5% reported that the new process had a positive or neutral effect on their satisfaction with care transitions.
Conclusion: The adoption of a standardized care transition process markedly decreased clinically relevant communication errors without lengthening checkout duration.
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Security, Violent Events, and Anticipated Surge Capabilities of Emergency Departments in Washington State
Background: Over the past 15 years, violent threats and acts against hospital patients, staff, and providers have increased and escalated. The leading area for violence is the emergency department given its 24/7 operations, its role in patient care, admissions gateway, and the center for influxes during acute surge events.
Objectives: This investigation had three objectives: to assess the current security of Washington State EDs, to estimate the prevalence of and response to threats and violence in Washington State EDs, and to appraise the Washington State ED security capability to respond to acute influxes of patients, bystanders, and media during acute surge events.
Methods: A voluntary, blinded, 28-question web-based survey developed by ED physicians was electronically delivered to all 87 Washington State ED Directors in January 2013. Responses were evaluated by descriptive statistical analyses.
Results: Analyses occurred after 90% (78/87) of ED Directors responded. Annual censes of the EDs ranged from < 20,000 to 100,000 patients and represented the entire spectrum of practice environments, including critical access hospitals to a regional quaternary referral medical center. Thirty-four of 75 (45%) reported the current level of security was inadequate based on the general consensus of their ED staff. Nearly two-thirds (63%) of EDs had 24-hour security personnel coverage, 28% reported no assigned security personnel. Security personnel training was provided by 45% of hospitals or health care systems. Sixty-nine of 78 (88%) respondents witnessed or heard violent threats or acts occurring in their ED. Of these, 93% were directed towards nursing staff, 90% towards physicians, 74% towards security personnel, and 51% towards administrative personnel. Nearly half (48%) noted incidents directed towards another patient, and 50% towards a patient’s family or friend. These events were variably reported to the hospital administration. After an acute surge event, 35% believed the initial additional security response would not be adequate and 26% reporting no additional security would be available within 15 minutes.
Conclusion: Our study reveals the variability of ED security staffing and a heterogeneity of capabilities throughout Washington State. These deficiencies and vulnerabilities are likely shared by and relevant for other EDs and regional emergency preparedness planners.
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Accelerated diagnostic pathways (ADPs) have been designed to identify low risk chest pain patients in the emergency department. This review article discusses the ASPECT score, the ADAPT score, the EDACS score, the HEART score and the HEART pathway. These ADPs have been validated in various studies, and aid the emergency provider with identifying the low risk chest pain patient that is appropriate for discharge home, while at the same time highlighting those patients who would benefit from further in patient work up. These approaches should be pared with patient input and shared decision making strategies.
Technology in Emergency Care
Pediatric obesity threatens the efficacy of life-saving medications given intramuscularly to anaphylactic patients. Epinephrine auto-injector needle lengths are potentially too short to reach the muscle compartment in patients with elevated body habitus. The objective of the study was to determine needle length requirements for intramuscular injections in pediatric patients.
Ultrasound was used to measure the distance from skin to muscle compartment of the thigh in 200 pediatric patients of various weight and body mass index who presented to the Emergency Department.
Patients with higher body mass index had an increased distance to muscle and bone. If current auto-injector recommendations were followed, 12% of patients weighing less than 30 kilograms and 9% of patients weighing more than 30 kilograms would have potentially used an auto-injector inadequate in needle length.
With the increase in childhood obesity, auto-injector needle lengths may be too short to effectively deliver medications. Needle length should be evaluated to accommodate pediatric patients with increased skin to muscle distance.
While only 15-20% of patients with foot and ankle injuries presenting to urgent care centers have clinically significant fractures, most undergo radiography. We examined the impact of electronic point-of-care clinical decision support (CDS) on adherence to the Ottawa Ankle Rules (OAR) as well as use and yield of foot and ankle radiographs in patients with acute ankle injury.
Institutional Review Board approval was obtained for this randomized controlled study performed April 18, 2012 through December 15, 2013. All ordering providers credentialed at an urgent care affiliated with a quaternary care academic hospital were randomized to either receive or not receive CDS, based on the OAR and integrated into the physician order entry system, with feedback at the time of imaging order. If the patient met OAR low-risk criteria, providers were advised against imaging and could either cancel the order or ignore the alert. Patients with foot and ankle complaints were identified via ICD-9 billing codes and electronic health records and radiology reports reviewed for those who were eligible. Chi-square was used to compare adherence to the OAR (primary outcome), radiography utilization rate and radiography yield of foot and ankle imaging (secondary outcomes) between the intervention and control groups.
Of 14,642 patients seen at urgent care during the study period, 613 (4.2%, representing 632 visits) presented with acute ankle injury and were eligible for application of the OAR; 374 (59.2%) of these were seen by control group providers. In the intervention group, CDS adherence was higher for both ankle (239/258=92.6% vs. 231/374=61.8%, p=0.02) and foot radiography (209/258=81.0% vs. 238/374=63.6%; p<0.01). However, ankle radiography use was higher in the intervention group (166/258=64.3% vs. 183/374=48.9%; p<0.01) while foot radiography use (141/258=54.6% vs. 202/374=54.0%; p=0.95) was not. Radiography yield was also higher in the intervention group (26/307=8.5% vs. 18/385=4.7%; p=0.04).
Clinical Decision Support, previously demonstrated to improve guideline adherence for high-cost imaging, can also improve guideline adherence for radiography – as demonstrated by increased OAR adherence and increase imaging yield.
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Intravascular volume status is an important clinical consideration in the management of the critically ill. Point of care ultrasonography (POCUS) has gained popularity as a non-invasive means of intravascular volume assessment via examination of the inferior vena cava (IVC). However, there is limited data comparing different acquisition techniques for IVC measurement by POCUS.
The goal of this evaluation is to determine the reliability of three IVC acquisition techniques for volume assessment: sub-xiphoid transabdominal long axis (LA), transabdominal short axis (SA), and right lateral transabdominal coronal long axis (CLA) (aka “rescue view”).
Volunteers were evaluated by three experienced emergency physician sonographers (EP). Gray scale (B-mode) and Motion-mode (M-mode) diameters were measured and IVC collapsibility index (IVCCI) calculated for three anatomic views (LA, SA, CLA). For each IVC measurement, descriptive statistics, intra-class correlation coefficients (ICC), and 2-Way Univariate Analyses of Variance (ANOVA) were calculated.
Thirty-nine volunteers were evaluated yielding 351 total US measurements. Measurements of the three views had similar means (LA 1.9 ± 0.4cm; SA 1.9 ± 0.4cm; CLA 2.0 ± 0.5cm). For B-Mode, LA had the highest ICC (0.86, 95% CI = 0.76 to 0.92) while CLA had the poorest ICC (0.74, 95% CI = 0.56 to 0.85). ICCs for all M-mode IVCCI were low. Significant interaction effects between anatomical view and EP were observed for B-mode and M-mode measurements. Post-hoc analyses reveal difficulty in consistent view acquisition between EPs.
Inter rater reliability of the IVC by EPs was highest for B-mode LA and poorest for all M-Mode IVC collapsibility indices (IVCCI). These results suggest that B-mode LA holds the most promise to deliver reliable measures of IVC diameter. Future studies may focus on validation in a clinical setting as well as comparison to a reference standard.
We propose using compression sonography to observe the deformation and collapse of the radial artery as a surrogate for automated cuff blood pressures. We hypothesize that the pressure required to achieve coaptation and complete collapse of the artery will correlate to the diastolic and systolic blood pressure, respectively.
Our primary aim was to assess the feasibility of Ultrasound-guided Radial Artery Compression (URAC) for blood pressure measurement. Our secondary aim was to compare patient comfort levels during automated cuff and URAC measurements.
This was a prospective cohort study with a convenience sampling of 25 adult patients at a single urban ED. URAC pressure was measured followed by cuff manometry on the same arm. A 100mL NS bag was connected to the Stryker pressure monitor and placed on the volar wrist. Pressure was applied to the bag with a linear transducer and the radial artery was observed for coaptation of the anterior and posterior walls (diastolic pressure) and complete collapse (systolic pressure). Pressures were subsequently recorded. Patient level of comfort was also documented during the URAC method, with patients reporting either ‘more’, ‘same’ or ‘less’ comfort in comparison to automated cuffs. Data were analyzed using intraclass correlation and paired t-tests.
The mean cuff systolic BP was 138.6 ± 22.1 mmHg compared to 126.9 ± 19.8 mmHg for the URAC systolic BP(p=0.02). For diastolic blood pressure, there was no significant difference between the cuff BP and the URAC BP (83.7 ± 13.0 cuff vs. 86.5 ± 19.8 URAC, p=0.46). The intraclass correlation (ICC) for systolic BP was 0.48 (p=0.04) and 0.57 (p=0.02) for diastolic BP. 80% (20/25) of subjects found the URAC method more comfortable than the cuff measurement, and the remainder found it the same (5/20).
This preliminary study concluded there was a statistically significant moderate correlation between automated cuff and URAC measurements, though stronger for the diastolic measurement. Additionally, most patients found the URAC method more comfortable than traditional cuff measurements. Compression ultrasonography shows promise as a surrogate for BP measurement, though future studies are needed.
Patients commonly present with an acute red eye to the emergency department. It is important to distinguish between benign and sight-threatening diagnoses. Here we provide a comprehensive overview on the acute red eye in the emergency department.
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Introduction End-of-shift evaluation (ESE) forms, also known as daily encounter cards, represent a subset of encounter-based assessment forms. Encounter cards have become prevalent for formative evaluation, with some suggesting a potential for summative evaluation. Our objective was to evaluate the inter-rater agreement of ESE forms using a single scripted encounter at a conference of emergency medicine (EM) educators.
Methods Following institutional review board exemption a scripted video simulating an encounter between an intern and a patient with an ankle injury was created. That video was shown during a lecture at the Council of EM Residency Director’s Academic Assembly with attendees asked to evaluate the “resident” using 1 of 8 possible ESE forms randomly distributed. Descriptive statistics were used to analyze the results with Fleiss’ Kappa to evaluate inter-rater agreement.
Results Most of the 324 respondents were leadership in residency programs (66%). Despite that, few individuals (5%) felt they were experts in assessing residents based on EM milestones. Fleiss’ Kappa ranged from 0.157 - 0.308 and did not perform much better in two post-hoc subgroup analyses.
The kappa ranges found show only slight to fair inter-rater agreement and raise concerns about the use of ESE forms in assessment of EM residents. Despite limitations present in this study, these results and a lack of other studies on inter-rater agreement of encounter cards should prompt further studies of such methods of assessment. Additionally, EM educators should focus research on methods to improve inter-rater agreement of ESE forms or other evaluating other methods of assessment of EM residents.
Objectives: To determine if scores on review quizzes delivered by an audience response system (ARS) correlate with in-training exam (ITE) scores. Methods: Prospective observational study of EM residents at 6 accredited EM residency programs. Subjects included residents who had taken previous in-training examinations. Subjects participated in bimonthly review sessions using an audience response system. Twelve review quizzes were administered, each consisting of 10 multiple choice questions. After the in-training exam, subjects completed an attitudinal survey consisting of six Likert scale items and one “yes/no” item. A mixed linear model was used to analyze the data accounting for prior 2012 in-training exam scores and nesting due to institution. Results: Among 192 participants, data from 135 (70.3%) participants were analyzed. Results from the mixed linear model indicate that the total mean score on the review quizzes was a significant [t(127) = 6.68; p < 0.001] predictor of the 2013 in-training exam score after controlling for the 2012 in-training exam score. 146 participants completed the attitudinal survey. 96% of respondents stated that they would like ARS to be used more often in resident education. Respondents felt the sessions aided in learning (mean 7.7/10), assisted in preparation for the in-training exam (mean 6.7/10), and helped identify content areas of weakness (mean 7.6/10). Conclusion: Our results suggest that scores from review quizzes delivered by an audience response system correlate with in-training exam scores and is viewed positively by residents.
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Introduction: The WestJEM Blog and Podcast Watch presents high quality open access educational blogs and podcasts in emergency medicine (EM) based on the ongoing ALiEM Approved Instructional Resources (AIR) and AIR-Professional series. Both series critically appraise resources using an objective scoring rubric. This installment of the Blog and Podcast Watch highlights the topic of orthopedic emergencies from the AIR series.
Methods: The AIR series is a continuously building curriculum which follows the Council of Emergency Medicine Residency Director’s (CORD) annual testing schedule. For each module, relevant content is collected from the top 50 Social Media Index sites published within the previous 12 months, and scored by 8 board members using 5 equally weighted measurement outcomes: Best Evidence in Emergency Medicine (BEEM) score, accuracy, educational utility, evidence based, and references. Resources scoring ≥30 out of 35 available points receive an AIR label. Resources scoring 27-29 receive an Honorable Mention label, if the executive board agrees that the post is accurate and educationally valuable.
Results: A total of 87 blog posts and podcasts were evaluated. Key educational pearls from the 3 AIR posts and the 14 Honorable Mentions are summarized.Conclusion: The WestJEM Blog and Podcast Watch series is based on the AIR and AIR-Pro series, which attempts to identify high quality educational content on open-access blogs and podcasts. This series provides an expert-based, post-publication curation of educational social media content for EM clinicians with this installment focusing on orthopedic emergencies.
Introduction: Interviewing for residency is a complicated and often expensive endeavor. Literature has estimated interview costs of $4,000 to $15,000 per applicant, mostly attributable to travel and lodging. The authors sought to reduce these costs and improve the applicant interview experience by coordinating interview dates between two residency programs in .
Methods: Two emergency medicine residency programs scheduled contiguous interview dates for the 2015-2016 interview season. A survey was used to assess applicant experiences interviewing in and attitudes regarding coordinated scheduling. Data on utilization of coordinated dates were obtained from interview scheduling software. The target group for this intervention consisted of applicants from medical schools outside that completed interviews at both programs.
Results: Of the 158 applicants invited to both programs, 84 (53%) responded to the survey. Scheduling data was available for all applicants. The total estimated cost savings for target applicants coordinating interview dates was $18,600. The majority of target applicants reported that this intervention increased the ease of scheduling (84%), made them less likely to cancel the interview (82%) and saved them money (71%).Conclusions: Coordinated scheduling of interview dates was associated with significant estimated cost savings and was reviewed favorably by applicants across all measures of experience. Expanding use of this practice geographically and across specialties may further reduce the cost of interviewing for applicants.
Introduction: There are no existing data on whether performance on USMLE predicts success in ABEM certification. Aim of this study was to determine the presence of any association between USMLE scores and first-time success on the ABEM Qualifying and Oral Certification Examinations.
Methods: USMLE Step 1, Step 2 CK scores and pass/fail results from the first-attempt at ABEM qualifying and oral examinations from residents graduating between 2009 and 2011 from 9 emergency medicine programs were retrospectively collected. A composite score was defined as the sum of USMLE Step 1 and Step 2 CK scores.
Results: Sample was composed of 197 residents. Median Step 1, Step 2 CK and composite scores were 218 ([IQR] 207-232), 228 (IQR 217-239) and 444 (IQR 427-468). First-time pass rates were 95% for the qualifying examination and 93% for both parts of the examination. Step 2 CK and composite scores were better predictors of achieving ABEM initial certification compared to Step 1 score (area under the curve 0.800, 0.759 and 0.656). Step 1 score of 227, Step 2 CK score of 225 and composite score of 444 predicted a 95% chance of passing both boards.
Conclusion: Higher USMLE Step 1, Step 2 CK and composite scores are associated with better performance on ABEM examinations with Step 2 CK being the strongest predictor. Cutoff scores for USMLE Step 1, Step 2 CK and composite score were established to predict first-time success on ABEM Initial Certification.