Accidents & Violence, Author Interviews, Emergency Care / 15.06.2016 Interview with: Angela Sauaia MD PhD Professor of Public Health, Medicine, and Surgery University of Colorado Denver What is the background for this study? What are the main findings? Authors: Americans mourn firearm related fatalities every day. Mass shootings are just the tip of the iceberg of the daily tragedy witnessed by trauma surgeons in emergency rooms. Industries strive to reduce the perils associated with motor vehicles, pedestrian and bicycles accidents, just to cite a few, through technology and education. Firearms move in the exact opposite direction. They are becoming progressively more dangerous and we have done little in terms of education to prevent accidents. The same trend is true for monitoring statistics. It is not difficult to obtain statistics on which type of car was associated with more accidents or fatalities. Conversely, trying to obtain data on which type of firearms are more likely to result in accidents or death is extremely difficult. We used the best data we could find and found that, contrary to every other injury mechanism, firearm injuries are becoming more lethal. In simple words, if you get into a car accident today, you are more likely to survive it due to improvements in trauma care and safety of vehicles than 10 years ago. On the other hand, if you get shot today, you are more likely to die than if you were shot 10 years ago, despite our excellent trauma care. (more…)
Author Interviews, Emergency Care, Heart Disease, Opiods / 05.05.2016 Interview with: William Eggleston, PharmD Fellow in Clinical Toxicology/Emergency Medicine Upstate Medical University Upstate New York Poison Center What is the background for this study? What are the main findings? Dr. Eggleston: The case series describes two deaths associated with loperamide abuse with supportive post-mortem findings. It adds to the growing body of literature reporting cardiac toxicity after loperamide abuse and demonstrates the deadly consequences. It also highlights the growing trend of loperamide abuse amongst opioid addicted patients looking to get high or stave off withdrawal symptoms. What should readers take away from your report? Dr. Eggleston: Readers should recognize that loperamide is an OTC opioid medication that acts similarly to morphine or heroin in the body after high doses. The drug is easily abused due to its low cost, ease of accessibility, legal status, and lack of social stigma associated with its possession. Most importantly, loperamide is a cardiac toxin that causes conduction disturbances in high doses and can produce deadly dysrhythmias. (more…)
Author Interviews, Emergency Care, Infections, JAMA, Pediatrics, Pulmonary Disease, Respiratory / 29.02.2016 Interview with: Suzanne Schuh, MD, FRCP(C), ABPEM The Hospital for Sick Children affiliated with the University of Toronto Medical Research: What is the background for this study? Dr. Schuh: Routine measurement of oxygen saturation in bronchiolitis is sometimes used as a proxy for illness severity, despite poor correlation between these parameters. This focus on oximetry may in part relate to lack of evidence on the natural history of desaturations in bronchiolitis which are often transient, and frequently not accompanied by increased respiratory distress. Desaturations occurring in infants with mild bronchiolitis in an ED often result in hospitalizations or prolonged hospital stay. They occur in healthy infants and may also occur in infants with mild bronchiolitis at home. The main objective of this study of infants with acute bronchiolitis was to determine if there is a difference in the proportion of unscheduled medical visits within 72 hours of ED discharge in infants who desaturate during home oximetry monitoring versus those without desaturations. Our study shows that the majority of infants with mild bronchiolitis experience desaturations after discharge home. (more…)
Annals Internal Medicine, Author Interviews, Emergency Care, Gout, Pharmacology / 23.02.2016 Interview with: Professor Timothy H Rainer  MD MBBCh Director, Accident & Emergency Medicine Academic Unit The Chinese University of Hong Kong  Medical Research: What is the background for this study? What are the main findings? Prof. Rainer: Gout is a type of arthritis characterised by periodic attacks of acute joint swelling and severe pain, and  often treated with colchicine or nonsteroidal anti-inflammatory drugs (NSAIDs).  Two recent randomized, controlled trials showed that oral prednisolone, a corticosteroid, was as effective as NSAIDs in the treatment of acute gout, but these studies involved small numbers of patients.  The researchers investigatedwhether oral prednisolone was as effective and safe as indomethacin (a NSAID) in a larger sample of patients who had acute gout symptoms and who were seen in the emergency department (ED) setting. Patients in both the prednisolone and indomethacin groups had clinically meaningful decreases in their pain levels during the 2 hours they were observed in the ED as well as during the 14-day follow-up period. Both groups had a similar decrease in pain levels. No major adverse events were reported in either group although there were more minor adverse events in the indomethacin group. (more…)
Author Interviews, Emergency Care, Surgical Research, Weight Research / 19.02.2016 Interview with: Junaid A. Bhatti, MBBS, MSc, PhD Sunnybrook Health Sciences Centre Research Institute Toronto, Canada  Medical Research: What is the background for this study? What are the main findings? Dr. Bhatti: Weight loss surgeries are consistently increasing in the US. While the positive impact of surgery on patient’s health are undebatable, limited information is available about long-term healthcare utilization, especially, emergency care utilization in bariatric surgery patients. This study compared emergency care utilization in bariatric patients three years following surgery to that of three years prior to surgery. Overall, we found that emergency care utilization increased by about 17% following surgery compared to the before surgery period. While complaints related to cardiovascular, ear, respiratory, and dermatology decreased, the complaints related to gastrointestinal, genitourinary, mental health, and substance misuse increased following surgery.  (more…)
Author Interviews, Emergency Care, Mental Health Research / 19.02.2016 Interview with: Paul E Ronksley, PhD Assistant Professor Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary, AB Canada Medical Research: What is the background for this study? Response: Numerous studies have shown that high users of the emergency department (ED) are often patients with complex medical needs and limited personal and social resources. It is also recognized that high users are a heterogeneous group driven by variability in the operational definition used to define this patient population. “High use” of ED services is often defined by the number of visits per year (namely ≥3 or ≥4 visits to the ED in a 1-year period) with little exploration of the distribution/pattern of these visits over time. The purpose of our study was to examine patient and encounter-level factors and costs related to periods of short-term resource intensity (clustered ED visits) among high users of the ED within a tertiary-care teaching facility. This is important as it may inform interventions that can focus on a more defined group with the goal of providing the needed care in a setting outside of the ED. Medical Research: What are the main findings? Response: Our main findings demonstrate that among high  emergency department users (i.e. patients with 3 or more ED visits in a 1-year period), approximately 1 in 7 patients had a period of high-intensity ED use (3 or more visits clustered within a week). These patients with clustered visits were more likely to be homeless, require psychiatric emergency services, and revisit the  emergency department for the same presenting complaints. The high-intensity users were also less likely to be admitted, more likely to leave without being seen and had lower costs per encounter, although their total ED cost across all visits was higher. (more…)
Author Interviews, Cost of Health Care, Emergency Care / 30.01.2016 Interview with: Jonathan Pinkney MD FRCP Professor of Medicine Plymouth University and Peninsula Schools of Medicine and Dentistry Centre for Clinical Trials and Population Studies Plymouth Science Park Phase 1 Honorary Consultant Physician Diabetes and Endocrinology University Medicine Derriford Hospital Plymouth Hospitals NHS Trust Plymouth UK Medical Research: What is the background for this study? Dr. Pinkney: The background is that the study was funded by the National Institute for Health Research in response to a call for research on the problem of unscheduled emergency admissions to hospitals in the UK. The rates of patient attendance at emergency departments and subsequent acute admissions to hospitals have risen year on year. Rising numbers of admissions have significant knock-on effects for acute hospitals including crowding in emergency departments, pressures on staffing, and disruption of elective treatment because of high rates of bed occupancy. The increase in admissions has been associated largely with increased short stay admissions. As a result, there has been an increasing view that a significant proportion of acute medical admissions may not be necessary, and in this respect may be said to be avoidable. There had been relatively limited research on how hospitals can best reduce these avoidable admissions. The main aims of the study were to investigate how senior staff in four major acute hospitals in south west England endeavour to avoid unnecessary acute admissions, and to examine a range of different systems in place in different hospitals to avoid unnecessary admissions. We called this project the "3A" or Avoidable Acute Admissions study. The 3A study was a mixed methods study with a strong emphasis on the narrative experience of patients, carers and healthcare professionals in the emergency departments and associated units of these four acute hospitals. The quantitative component of the study was an application of Value Stream Mapping (VSM), a technique from lean theory, and this was used to identify and measure points of delay in the patient journey. (more…)
Author Interviews, Emergency Care, Social Issues / 29.01.2016 Interview with: Jessica Moe MD, MA, PGY4 FRCPC Emergency Medicine MSc (Candidate) Clinical Epidemiology RCPS Emergency Medicine Residency Program University of Alberta Edmonton, Alberta Medical Research: What is the background for this study? What are the main findings? Dr. Moe: Patients who leave the emergency department (ED) prior to completing their care account for a substantial number of annual visits; some of these patients are at high medical risk. We used the National Hospital Ambulatory Medical Care Survey from 2009-2011 to examine a nationally representative sample of patients who left the ED prior to completing care. Our work suggests that, among patients who leave the ED prematurely, the degree of medical risk may be related to whether or not these patients saw a medical professional prior to leaving the ED. Patients who leave prior to medical evaluation are generally younger and present with lower acuity visits, whereas patients who leave after medical evaluation tend to be older, are more likely to arrive by ambulance and have higher acuity visits. (more…)
Author Interviews, Emergency Care, Hepatitis - Liver Disease, NYU / 26.01.2016

Dr Waridibo Allison MD PhD Department of Medicine, Division of Infectious Diseases and Immunology New York Langone University School of Medicine New York, NY Interview with: Dr Waridibo Allison MD PhD Department of Medicine, Division of Infectious Diseases and Immunology New York Langone University School of Medicine New York, NY 10016 Medical Research: What is the background for this study? What are the main findings? Dr. Allison: It was found that among 383 baby boomers presenting to a large urban emergency department in New York City the prevalence of HCV antibody reactivity was 7.3%. Only four patients were successfully linked to care and only one patient was started on HCV treatment. The study highlights the possibility that there may be problems in linking patients to care from the ED compared to other clinical settings such as primary care and inpatient settings. It was concluded that only with strategies to improve linkage to care could a screening program for baby boomers be recommended in the ED where the study was carried out. The study additionally had a qualitative component and, via structured interviews, evaluated knowledge about HCV infection amongst baby boomers presenting to the ED. Overall knowledge was good but some misconceptions about transmission persisted and many patients mistakenly believed that there is a vaccine for hepatitis C. (more…)
Annals Internal Medicine, Author Interviews, Emergency Care, Opiods, Pain Research / 29.12.2015 Interview with: Marc R. Larochelle, MD, MPH Assistant Professor of Medicine Boston Medical Center Boston, MA  Medical Research: What is the background for this study? What are the main findings? Dr. Larochelle: More than 16 thousand people in the United States die from prescription opioid overdose each year. However, morbidity extends well beyond fatal overdose - nearly half a million emergency department visits each year are related to prescription opioid-related harms. Emergency department visits for misuse of opioids represent an opportunity to identify and intervene on opioid use disorders, particularly for patients who receive prescriptions for opioids to treat pain. We examined a cohort of nearly 3000 commercially insured individuals prescribed opioids for chronic pain who were treated for a nonfatal opioid overdose in an emergency department or inpatient setting. We were interested in examining rates of continued prescribing after the overdose and the association of that prescribing with risk of repeated overdose. We found that 91% of individuals received another prescription for opioids after the overdose. Those continuing to receive opioids at high dosages were twice as likely as those whose opioids were discontinued to experience repeated overdose. (more…)
Author Interviews, Biomarkers, Emergency Care, Heart Disease / 21.12.2015 Interview with: Florence Leclercq, MD, PhD Department of Cardiology Arnaud de Villeneuve Hospital University hospital of Montpellier Montpellier,France Medical Research: What is the background for this study? What are the main findings? Response: Patients with history of coronary artery disease (CAD) are considered as a population with high risk of further coronary eventsHowever, frequent pre-existing ECG changes observed in these patients result in difficulty interpreting new ECG aspects in case of chest discomfort. Furthermore, anxiety frequently induced non-cardiac causes of chest pain in these patients, leading to unjustified admission to cardiology units.  Moreover, levels of troponin are usually higher in patients with previous CAD compared to patients without history of angina, resulting in difficulty interpreting baseline values in this population.  Conversely, copeptin may be influenced by the severity of myocardial ischemia and resulting endogenous stress, and could be a useful additional marker to exclude severe coronary stenosis in high-risk patients with recent chest pain. This propective monocentric study evaluates the incremental value of copeptin associated with high-sensitivity cardiac T troponin (hs-cTnT) to exclude severe coronary stenosis in 96 patients with coronary artery disease  (CAD) and acute chest pain.   Mean age of patients was 60 +/- 13.8 years and the mean time between chest pain onset and blood samples of copeptin was 4.2 +/-2.7 hours. According to clinical decision, coronary angiography was performed in 71 patients (73.9 %) and severe stenosis diagnosed in 14 of them (14.6%). No ischemia was detected on SPECT imaging (n=25). Among the 69 patients with a negative kinetic of hs-cTnT and a negative baseline copeptin, 5 (7.4%) had a severe stenosis (NPV 0.93; 95% CI: 0.87-0.99), 4 of them related to in-stent restenosis (NPV for exclusion of native coronary stenosis: 0.98; 95% CI: 0.93-1). We can conclude that in patients with preexisting CAD, and once Acute Myocardial Infarction (AMI) is excluded, copeptin increases the NPV of  hs-cTnT  to rule out severe coronary stenosis or significant myocardial ischemia. Coronary stenosis not detected with this strategy concerned exclusively in-stent restenosis or stenosis related to infarcted -related  coronary artery without myocardial viability. (more…)
Author Interviews, Biomarkers, Emergency Care, Heart Disease / 10.12.2015 Interview with: Justin A. Ezekowitz, MBBCh MSc Associate Professor, University of Alberta Co-Director, Canadian VIGOUR Centre Cardiologist  and Director, Heart Function Clinic Nariman Sepehrvand, MD Research Fellow & Graduate Student Mazankowski Alberta Heart Institute University of Alberta Edmonton, Canada  Medical Research: What is the background for this study? Dr. Ezekowitz: Major practice guidelines recommend the use of natriuretic peptide (NP) testing for diagnosing acute heart failure (HF) in emergency departments (ED). Despite these guidelines, the majority of healthcare regions all around the world (except for the United States and New Zealand) have restricted access to NP testing due to concerns over cost to healthcare systems. In the province of Alberta, Canada, however, a province-wide access to NP testing was provided for all EDs in 2012. This study investigates the factors that are related to the utilization of NP testing in EDs. Medical Research: What are the main findings? Dr. Ezekowitz: There was a substantial geographic variation in testing for NPs, despite having a single payer system and the universal availability of NP testing in Alberta. Several factors (including male sex, some comorbidities like prior heart failure, urban residence, type of care provider and ED clinical volume) influenced the utilization of testing for NPs in routine ED practice. Interestingly, patients with heart failure who were tested for NPs at ED, had a higher rate of hospital admission and lower 7 day and 90 day repeat ED visit rates compared to those who were not tested. (more…)
Anesthesiology, Author Interviews, Emergency Care, Pain Research / 09.12.2015 Interview with: Michael D. April, MD, DPhil Department of Emergency Medicine San Antonio Uniformed Services Health Education Consortium San Antonio, TX  Medical Research: What is the background for this study? What are the main findings? Dr. April: Anesthesia research studies have found that nasal inhalation of isopropyl alcohol has efficacy in treating nausea among post-operative patients. We sought to study this agent among Emergency Department patients with nausea or vomiting. We found that patients randomized to inhale isopropyl alcohol had improved self-reported nausea scores compared to patients randomized to inhale saline (placebo). MedicalEditor's note:  Do Not Do This Without Medical Supervision! (more…)
Author Interviews, Cleveland Clinic, Emergency Care, JAMA, Stroke, Telemedicine / 08.12.2015 Interview with: Ken Uchino, MD FAHA FANA Director, Vascular Neurology Fellowship Research Director, Cerebrovascular Center, Cleveland Clinic Associate Professor of Medicine (Neurology) Cleveland Clinic Lerner College of Medicine of CWRU Cleveland, OH 44195 Medical Research: What is the background for this study? What are the main findings? Dr. Uchino: Treatment for acute ischemic stroke is time dependent. Multiple studies have reported strategies to improve time to treatment after arrival in the hospital. Mimicking pre-hospital thrombolysis of acute myocardial infarction pioneered 30 years ago, two groups in Germany have implemented pre-hospital ischemic stroke thrombolysis using mobile stroke unit (“stroke ambulance”) that includes CT scan and laboratory capabilities. These units have been demonstrated to provide stroke treatment earlier than bringing patients to the emergency departments. Our report extends the concept mobile stroke unit further by using telemedicine for remote physician presence. The other mobile stroke units were designed to have at least one physician on board. This allows potential multiple or geographically distant units to be supported by stroke specialists. The study demonstrates that after patient arrival in the ambulance, the time to evaluation (CT scanning and blood testing) and to thrombolytic treatment is as quick or better as patient arrival in emergency department door. We are reporting the overall time efficiency after emergency medical service notification (911 call) in a separate paper. (more…)
Author Interviews, Blood Pressure - Hypertension, Emergency Care, Vanderbilt / 24.11.2015 Interview with: Candace D. McNaughton, MD MPH FACEP Assistant Professor Emergency Medicine Research Department of Emergency Medicine, Research Division Vanderbilt University Medical Center Medical Research: What is the background for this study? What are the main findings? Dr. McNaughton: Hypertension, or high blood pressure, affects 1/3rd of adults in the United States and more than 1 billion people worldwide.  It is also the #1 risk factor for cardiovascular disease such as heart attack and stroke, so it is very important to treat. The burden of hypertension in the emergency department is not well understood.  The ER is not usually thought of as a place where perhaps we could or should be addressing hypertension; that has traditionally be left up to primary care providers. Through this study, our goals were to gain a better understanding of how many ER visits were either related to hypertension or were solely because of hypertension, and to determine whether this changed from 2006 to 2012. We found that emergency room visits related to or solely for hypertension were common and that they both rose more than 20% from 2006 to 2012. Visits to the emergency department specifically for hypertension were more common among patients who were younger, healthier, and less likely to have health insurance. Despite increases in the number of ER visits related to hypertension, the proportion of patients who were hospitalized did not increase; this suggests that doctors in emergency departments may be more aware of hypertension and/or may be managing it without having to hospitalize patients. (more…)
Author Interviews, Emergency Care, Mental Health Research, Stanford / 22.11.2015 Interview with: Arica Nesper, MD, MAS Resident Physician Stanford/Kaiser Emergency Medicine Residency Stanford University Medical Center Department of Emergency Medicine Stanford Medical Research: What is the background for this study? What are the main findings? Dr. Nesper: Patients with severe mental illness are a distinct demographic in the emergency department. Unfortunately, resources to help these vulnerable patients are frequently the target of funding cuts. We aimed to describe the effect of these cuts on our emergency department and the care provided to our patients. In this study we evaluated data from before our county mental health facility cut its inpatient capacity by half and closed its outpatient unit, and compared this data with data collected after this closure. We found that the mean number of daily psychiatric consultations in our emergency department more than tripled and that the average length of stay for these patients increased by nearly eight hours. These two data combined demonstrate a five-fold increase in daily emergency department bed hours for psychiatric patients, placing a significant strain on the emergency department and demonstrating a delay in definitive care provided to these vulnerable patients. (more…)
Allergies, Asthma, Author Interviews, Emergency Care, Pediatrics / 07.11.2015 Interview with: Jill Hanson, MD Children’s Mercy Hospital Kansas City MO  Background from the American College of Allergy, Asthma & Immunology “Asthma is the most common chronic disease in children, and one of the most difficult to manage, which is one of the reasons there are so many emergency department visits for asthma sufferers in the US.” Medical Research: What are the main findings of this study? Dr. Hanson: Our study of asthmatic children found that the number of historical asthma-related acute care visits (i.e. urgent care, emergency department and inpatient admissions) was predictive of future asthma-related acute care visits.  (more…)
Author Interviews, Emergency Care, OBGYNE, Primary Care / 30.10.2015 Interview with: Alfred Sacchetti, M.D. Department of Emergency Medicine Our Lady of Lourdes Medical Center, Camden, NJ Thomas Jefferson University, Philadelphia, PA Medical Research: What is the background for this study? Dr. Sacchetti: Much of the value of the "Affordable Care Act" is based on the concept that a primary care provider will limit the need for Emergency Department visits.  Unfortunately, this has never been proven, particularly for women's health issues. The purpose of our study was to determine if a relationship with a primary care provider did limit the need to access Emergency Department services. Medical Research: What are the main findings? Dr. Sacchetti: What our results demonstrated was that patients with a primary care Obstetrical / Gynecologic provider utilized the emergency department to the same extent as patients without a documented primary OB/GYN relationship.   Patients with women's health issues still required the services of the ED, even with an established primary care provider.  What was very interesting was that Emergency Department use was not restricted to off hours in the evenings and on weekends.  In fact the use of the ED occurred as much during the 9-5 hours on the weekdays as it did during other times.  The majority of the ED visits were for ambulatory complaints, with most patients being discharged to home after their care. (more…)
Author Interviews, Emergency Care, Pain Research / 19.10.2015

Benjamin W. Friedman MD, MS Department of Emergency Medicine Montefiore Medical Center Albert Einstein College of Medicine Bronx, New Interview with: Benjamin W. Friedman MD, MS Department of Emergency Medicine Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York Medical Research: What is the background for this study? What are the main findings? Dr. Friedman: Low back pain is responsible for 2.4% of visits to emergency departments resulting in 2.7 million visits annually. Pain outcomes for these patients are generally poor. One week after an ED visit in an unselected low back pain population, 70% of patients report persistent back-pain related functional impairment and 69% report analgesic use. Three months later, 48% report functional impairment and 46% report persistent analgesic use. Treatment of  Low back pain with multiple concurrent medications is common in the ED setting. Data from a national sample show that emergency physicians often prescribe NSAIDs, skeletal muscle relaxants, and opioids in combination—26% of patients receive a NSAID combined with a skeletal muscle relaxant and 26% also receive an NSAID combined with an opioid. Sixteen percent of patients receive all three classes of medication. Several clinical trials have compared combination therapy with NSAIDS + skeletal muscle relaxants to monotherapy with just one of these agents. These trials have reported heterogeneous results. The combination of opioids + NSAIDS has not been well evaluated in patients with acute low back pain. Given the poor pain and functional outcomes that persist beyond an ED visit for musculoskeletal LBP and the heterogeneity in clinical care, we conducted a randomized comparative efficacy study with the following objective. To compare pain and functional outcomes one week and three months after ED discharge among patients randomized to a ten day course of: 1) naproxen + placebo 2) naproxen + cyclobenzaprine or 3) naproxen + oxycodone/acetaminophen. (more…)
Author Interviews, CDC, Emergency Care, Supplements / 17.10.2015 Interview with: Andrew I. Geller, M.D From the Division of Healthcare Quality Promotion Centers for Disease Control and Prevention Medical Research: What is the background for this study? What are the main findings? Dr. Geller: In recent years some dietary supplement products have been recalled for having unapproved ingredients or contaminants, but there is very little national data about how frequently dietary supplements that are not included in such recalls cause health problems. This study looks at how often people went to emergency departments (EDs) for problems caused by dietary supplements.
  • Supplements include herbals, complementary nutritionals (such as amino acid supplements), and vitamins and minerals.
  • We studied records from 63 emergency departments from 2004-2013.
  • We calculate that every year, dietary supplements cause:
  • More than 23,000 ED visits, and
  • More than 2,000 hospitalizations.
  • More than a quarter (28%) of these ED visits were among young adults (20-34 years).
  • More than half (56%) of the ED visits made by young adults were for problems with products for weight loss or increased energy.
  • Cardiac symptoms (irregular/fast heartbeat or chest pain) were common among patients with weight loss or energy supplement problems.
  • More than 20% were young children who got into supplements meant for someone else.
  • ED visits were less common among older adults, but more than 1 in 3 (36%) of these ED visits by older adults were for swallowing problems, such as choking on a pill, most commonly vitamin/mineral supplements.
Author Interviews, Cost of Health Care, Emergency Care, Health Care Systems / 17.10.2015 Interview with: James Galipeau PhD Ottawa Hospital Research Institute Ottawa, Ontario, Canada  Medical Research: What is the background for this study? Dr. Galipeau: Overcrowding in emergency departments (EDs) is becoming more and more commonplace in Canada. The issue of overcrowding is complex and multidimensional with three distinct but interdependent components: input, throughput (processing), and output. At the processing level, one solution to overcrowding that has emerged is the establishment of observation/short stay units. A short-stay unit is a physical location in a hospital, usually in close proximity to the ED. Patients needing treatments or observation that may take several hours to resolve (e.g., blood transfusions, diagnostic testing, arranging social services) can be accommodated in a short-stay unit without occupying ED beds or needing to be admitted. In theory, ED-based short-stay units can lessen ED overcrowding by influencing outcomes such as ED wait times and hospital costs (if patients are moved from the ED to inpatient care). Although a recent report by the American College of Emergency Physicians recommends pursuing the use of short-stay units to alleviate ED overcrowding, there is a lack of evidence syntheses summarizing their effectiveness, safety, and value for money. Our objective was to conduct a systematic review to evaluate the effectiveness and safety of ED short-stay units compared with care not involving short-stay units. (more…)
AHRQ, Author Interviews, Emergency Care, Health Care Systems / 15.10.2015

Ernest Moy, MD, MPH Medical Officer Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Interview with: Ernest Moy, MD, MPH Medical Officer Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Quality Medical Research: What is the background for this study? Dr. Moy: The amount of time that a patient spends in the emergency department (ED) has become increasingly viewed as a quality measure, because length of stay and ED crowding have been linked to quality of care, patient safety, and treatment outcomes. However, current ED length-of-stay measures publicly reported by the Centers for Medicare & Medicaid Services (CMS) combine lengths of stay across all conditions. We suspected that ED length of stay is influenced by the clinical condition of the patient, but didn’t know how disparate times might be. Of course, such stays will certainly be influenced by other factors, which we describe in the paper. Previous studies have helped guide decisions about where to focus resources to improve emergency department services. However, many studies about ED length of stay focus on a single condition, a single or few hospitals, or both, which limits what we can conclude across different conditions.  We were fortunate to find one state, Florida, in the Healthcare Cost and Utilization Project database that provides entry and exit times for a census of emergency department visits for both released and admitted patients to measure length of ED stays by patients’ conditions and dispositions. Medical Research: What are the main findings? Dr. Moy: For the 10 most common diagnoses, patients with relatively minor injuries (e.g., sprains and strains, superficial injuries and contusions, skin and subcutaneous tissue infections, open wounds of the extremities) typically required the shortest mean stays (3 hours or less). Conditions involving pain with nonspecific or unclear etiologies (e.g., chest, abdomen, or back pain; headache, including migraine), generally resulted in mean stays of 4 hours or more. However, there were substantial clinical differences among patients released, admitted, and transferred. Conditions resulting in admission or transfer tended to be more serious, resulting in longer stays. Patients requiring the longest stays, by disposition, had discharge diagnoses of nonspecific chest pain (mean 7.4 hours among discharged patients), urinary tract infections (4.8 hours among admissions), and schizophrenia (9.6 hours among transfers) among the top 10 diagnoses. (more…)
Accidents & Violence, Author Interviews, Emergency Care / 10.10.2015

Tracy Mehan, MA Manager of translational research Center for Injury Research at Policy The Research Institute at Nationwide Children’s Hospital Columbus, OH Interview with: Tracy Mehan, MA Manager of translational research Center for Injury Research at Policy The Research Institute at Nationwide Children’s Hospital Columbus, OH   Medical Research: What is the background for this study? What are the main findings? Response: We noticed an increasing number of ziplines popping up all over the United States and wanted to see if there were any potential safety concerns.  In 2001 there were only 10 commercial ziplines. By 2012, there were more than 200. If you include the number of ziplines now seen in backyards and in places like outdoor education programs and camps, the number skyrockets to over 13,000. We found that from 1997 through 2012, there were just under 17,000 non-fatal zipline-related injuries treated in US emergency departments. Almost 70 percent of these injuries occurred in the last four years of the study indicating that this is a growing problem. In 2012 alone, there were more than 3,600 zipline-related injuries, nearly 10 a day. The majority of the injuries were the result of a fall (77 percent) or a collision (13 percent) into a tree, a support structure, or another person. Close to half of the injuries were broken bones (46 percent) and one of every ten (11.7 percent) patients were admitted to the hospital. (more…)
Author Interviews, Clots - Coagulation, CT Scanning, Emergency Care, Geriatrics / 24.09.2015 Interview with: Dr Lim Beng Leong MBBS, MRCS (A&E), FAMS Jurong Health Services Emergency Department, Singapore  Medical Research: What is the background for this study? What are the main findings? Dr. Leong: It is common in the emergency department to see patients with warfarin who suffer a minor head injury (HI) with GCS >13. It is standard practice according to international guidelines to perform a plain CT scan of the head. What is contentious in the literature is the subsequent management of those patients with a normal initial CT scan. Practice is heterogeneous and includes a mandatory second CT scan at 24 hours mark or observation and repeat CT scan at the discretion of the attending doctor. We have found in our study that the "observe and repeat CT scan for symptomatic cases" approach only was safe as abnormal second CT scans were rare (1 in 295 cases). We traced the patients' course 2 weeks post discharge and none of the patients were re-admitted for reasons of delayed intra-cranial hemorrhage (ICH). However, the cohort of patients consist largely of geriatric patients with falls. More than 50% of these patients were hospitalized for more than 3 days; the longest of 2-3 weeks. They were likely to have various reasons that required longer hospitalizations apart from observation for delayed ICH, such as assessing for risk, etc. (more…)
Author Interviews, Emergency Care, Infections / 25.08.2015

John P. Haran MD Assistant Professor of Emergency Medicine University of Massachusetts Medical School, Worcester, MA Interview with: John P. Haran MD Assistant Professor of Emergency Medicine University of Massachusetts Medical School, Worcester, MA Medical Research: What is the background for this study? What are the main findings? Dr. Haran: The Infectious Disease Society of America (IDSA) publishes evidence based guidelines for the treatment of skin and soft tissue infections, however, how closely clinicians follow these guidelines is unknown. Observation units have been increasingly used over the past decade in emergency medicine for short-term care of patients for many medical conditions including skin infections. These units offer a great alternative to hospitalization especially for older adults. We set out to describe the treatment patterns used in the observation unit of an academic institute and compare them to the IDSA guidelines. We found that physicians had poor adherence to these guidelines. Additionally, we discovered that older adults were at increased risk of being over-treated while women were at increased risk for being under-treated. These age and gender biases are not new to medicine and emergency departments should standardize antibiotic treatments to reduce treatment bias. (more…)
Author Interviews, Columbia, Emergency Care, Race/Ethnic Diversity, Stroke / 14.08.2015

Heidi Mochari-Greenberger Ph.D., M.P.H Associate research scientist Columbia University Medical Center New York, Interview with: Heidi Mochari-Greenberger Ph.D., M.P.H Associate research scientist Columbia University Medical Center New York, N.Y MedicalResearch: What is the background for this study? Dr. Mochari-Greenberger: Differences in activation of emergency medical services (EMS) may contribute to race/ethnic and sex disparities in stroke outcomes. The purpose of this study was to determine whether EMS use varied by race/ethnicity or sex among a contemporary, diverse national sample of hospitalized acute stroke patients. MedicalResearch: What are the main findings? Dr. Mochari-Greenberger: Use of EMS transport among hospitalized stroke patients was less than 60% and varied by race/ethnicity and sex; EMS use was highest among white females and lowest among Hispanic males. Our analyses showed that Hispanic and Asian men and women were significantly less likely than their white counterparts to use EMS; black females were less likely than white females to use EMS, but black men had a similar rate to white men. These observed associations between race/ethnicity and sex with EMS use persisted after adjustment for stroke symptoms and other factors known to be associated with EMS use, indicating they were not driven solely by stroke symptom differences. (more…)
Author Interviews, Compliance, Cost of Health Care, Emergency Care, Primary Care, UCSD / 15.07.2015

Nadereh Pourat, PhD Professor, Department of Health Policy and Management, UCLA Fielding School of Public Health Adjunct Professor, UCLA School of Dentistry Director of Research, UCLA Center for Health Policy Interview with: Nadereh Pourat, PhD Professor, Department of Health Policy and Management, UCLA Fielding School of Public Health Adjunct Professor, UCLA School of Dentistry Director of Research, UCLA Center for Health Policy Research Medical Research: What is the background for this study? What are the main findings? Dr. Pourat: We have succeeded to insure most of the uninsured population in the U.S., but now have to figure out how to reduce costs while improving health. We had the opportunity to examine the role of continuity with a primary care provider, which is one of the pathways that looked promising in improving health and reducing costs. We were evaluating a major demonstration program in California called the Health Care Coverage Initiative (HCCI) and one of the participating counties implemented a policy to increase adherence by only paying for visits if patients went to their assigned providers. We examined what happened to patients who always or sometimes adhered to their provider versus those who never adhered. We found that adherence or continuity reduced emergency department use and hospitalizations. This would lead to savings because of the high costs of these services. Medical Research: What should clinicians and patients take away from your report? Dr. Pourat: The study shows that both patients and clinicians would benefit from continuity with the primary care provider. Clinicians can actually make a difference in helping patients: they can teach patients about self-care and help them manage their conditions better. Patients would benefit from following through with treatment plans and experience less medical error and duplication of services which are potentially harmful. Continuity fosters rapport and trust between patients and providers and can be beneficial to both. (more…)
Author Interviews, Emergency Care, FDA, Opiods, Pharmacology / 15.07.2015 Interview with: Christopher M. Jones, Pharm D., M.P.H Senior advisor, Office of Public Health Strategy and Analysis Office of the Commissioner, Food and Drug Administration Medical Research: What is the background for this study? Dr. Jones: Opioid analgesics and benzodiazepines are the two most common drug classes involved in prescription drug overdose deaths. In 2010, 75% of prescription drug overdose deaths involved opioid analgesics and 29% involved benzodiazepines. Opioid analgesics and benzodiazepines are also the most common drugs associated with emergency department visits due to nonmedical use of prescription drugs. Combined opioid and benzodiazepine use has been suggested as a risk factor for overdose death. Opioids and benzodiazepines have complex drug interactions and in combination can result in synergistic respiratory depression, but the exact mechanisms by which benzodiazepines worsen opioid-related respiratory depression are not fully understood. Widespread co-use of benzodiazepines and opioids has been documented in both chronic pain and addiction treatment settings. Studies suggest that among patients who receive long-term opioids for chronic non-cancer pain, 40% or more also use benzodiazepines. Among patients who abuse opioids, benzodiazepine abuse also is prevalent, and co-users report using benzodiazepines to enhance opioid intoxication. This study builds on the prior literature by analyzing trends on how the combined use of opioids and benzodiazepines in the U.S. contributes to the serious adverse outcomes of nonmedical use–related ED visits and drug overdose deaths. A better understanding of the consequences of co-use of these medications will help identify at-risk populations, inform prevention efforts, and improve the risk–benefit balance of these medications. Medical Research: What are the main findings? Dr. Jones: From 2004 to 2011, the rate of nonmedical use–related Emergency Department visits involving both opioid analgesics and benzodiazepines increased from 11.0 to 34.2 per 100,000 population. During the same period, drug overdose deaths involving both drugs increased from 0.6 to 1.7 per 100,000. Statistically significant increases in Emergency Department visits occurred among males and females, non-Hispanic whites, non-Hispanic blacks, and Hispanics, and all age groups except 12–17-year-olds. For overdose deaths, statistically significant increases were seen in males and female, all three race/ethnicity groups, and all age groups except 12–17-year-olds. Benzodiazepine involvement in opioid analgesic overdose deaths increased each year, increasing from 18% of opioid analgesic overdose deaths in 2004 to 31% in 2011. (more…)
Author Interviews, BMJ, Emergency Care, Pain Research / 25.06.2015 Interview with: Prof. Jason Smith Consultant in Emergency Medicine, Derriford Hospital, Plymouth, UK Royal College of Emergency Medicine Professor Defence Professor of Emergency Medicine, Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, UK Honorary Professor in Emergency Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry, UK Medical Research: What is the background for this study? Prof. Smith: Patients commonly present to emergency departments in pain. When patients are asked about their emergency department experience, they often say that more could have been done to manage their pain. Routine care for patients in moderate or severe pain who present to emergency departments usually involves intravenous (IV) morphine, delivered by a nurse. There may be a delay when patients are admitted to a hospital ward before they are reviewed by the admitting medical team, when their pain needs are reassessed. Patient controlled analgesia (PCA) is used to good effect elsewhere in the hospital. The aim of this study was to compare PCA with routine care in patients presenting to emergency departments with either traumatic injuries or non-traumatic abdominal pain, who require admission to hospital. Medical Research: What are the main findings? Prof. Smith: We found that significant reductions in pain were possible using patient controlled analgesia in patients with abdominal pain. Patients spent significantly less time in moderate or severe pain, and were more likely to be very or perfectly satisfied with their pain management. In patients with traumatic injuries, a modest (but non-significant) reduction in pain was seen in patients allocated to the PCA group compared with the routine care group. Patients in the PCA group were more likely to be very or perfectly satisfied with their pain management. (more…)
Anesthesiology, Author Interviews, Emergency Care, JAMA / 21.06.2015 Interview with: Christoph Czarnetzki MD, MBA Division of Anesthesiology Geneva University Hospitals Geneva, Switzerland Medical Research: What is the background for this study? What are the main findings? Dr. Czarnetzki: In the US, about 40 million patients undergo a general anesthetic each year, and approximately 12,000 broncho-aspirate. Broncho-aspiration of gastric juice may lead to acute respiratory distress syndrome, carrying a 40% mortality rate. The risk is increased 10-fold in patients undergoing emergency surgery. Trauma patients may have ingested food before their accident, or have swallowed blood from oral or nasal injuries. Also, gastric emptying is delayed due to head injury, stress, pain, and opioid medication. Non-trauma patients may have delayed gastric emptying due to paralytic ileus and critical illness, leading to significant residual stomach content even after long fasting periods. Erythromycin, a macrolide antibiotic, and motilin receptor agonist induces antral contractions, and increases the lower esophageal sphincter tone, which is an important barrier against gastro-esophageal reflux. Although gastric emptying properties of erythromycin are well known, its efficacy in patients undergoing emergency surgery has never been investigated before to our knowledge. In our study we included 132 patients undergoing general anesthesia for emergency procedures and we could show that erythromycin increased the proportion of clear stomach and decreased acidity of residual gastric liquid. Dependent of the definition of empty stomach (less than 40 ml and absence of solid food or completely empty stomach) the absolute risk reduction ranged from 17% to 24%, equivalent to a number needed to treat of four to six patients to produce one completely cleared stomach. Erythromycin was particularly efficacious in non-trauma patients. Adverse effects were minor. (more…)