Emergency Care
09 Dec ER Trial of Inhaling Isopropyl Alcohol From Pads Reduced Nausea
[caption id="attachment_19946" align="alignleft" width="72"]
Dr. April[/caption]
MedicalResearch.com 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!
08 Dec Telemedicine Can Support Rapid Stroke Treatment in Ambulances
[caption id="attachment_19812" align="alignleft" width="200"]
Dr. Ken Uchino[/caption]
MedicalResearch.com 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.
24 Nov ER Visits For Hypertension Common and Increasing
[caption id="attachment_19585" align="alignleft" width="144"]
Dr. McNaughton[/caption]
MedicalResearch.com 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.
22 Nov Decreased Funding For Mental Health Services Results in Crowded, Strained Emergency Rooms
[caption id="attachment_19545" align="alignleft" width="132"]
Dr. Nesper[/caption]
MedicalResearch.com 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.
07 Nov Model Predicts Children At High Risk For Asthma Related Acute Care Visits
MedicalResearch.com 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.30 Oct Having A Primary Care Doctor Does Not Reduce ER Visits For Women’s Health Issues
[caption id="attachment_18885" align="alignleft" width="192"]
Dr. Sacchetti[/caption]
MedicalResearch.com 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.
19 Oct Low Back Pain Remains Frustrating Problem For Emergency Rooms and Patients
MedicalResearch.com 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.
17 Oct Weight Loss and Dietary Supplements Linked To Thousands Of Emergency Room and Hospital Stays Annually
[caption id="attachment_4115" align="alignleft" width="83"]
Dr. Andrew Geller[/caption]
MedicalResearch.com 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.
17 Oct Short Stay Units May Save Money For Health Care Systems
[caption id="attachment_18476" align="alignleft" width="200"]
James Galipeau PhD[/caption]
MedicalResearch.com 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.
15 Oct Schizophrenia, Chest Pain Top Longest Emergency Department Stays
MedicalResearch.com 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.
10 Oct More Ziplines Means More Injuries—Nearly 10 A Day
MedicalResearch.com 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.
24 Sep Which Patients on Warfarin Need Repeat CT Scan after Head Injury?
MedicalResearch.com 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.25 Aug Study Finds Poor Adherence To Guidelines For Skin and Soft Tissue Infections
MedicalResearch.com 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.
14 Aug Asians and Hispanics May Underutilize EMS Services For Stroke Symptoms
MedicalResearch.com 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.
15 Jul Primary Care Continuity Reduced Emergency Department Use and Hospitalizations
Posted at 11:46h
in Author Interviews, Compliance, Cost of Health Care, Emergency Care, Primary Care, UCSD
MedicalResearch.com 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.
15 Jul Co-ingestion of Benzodiazepines and Opioids Contributes to Overdose and Death
MedicalResearch.com 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 2011.25 Jun Patient Controlled Medication Found Effective For Abdominal Pain In ER
MedicalResearch.com 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.21 Jun Erythomycin Allows Gastric Emptying To Prevent Aspiration In ER Patients
MedicalResearch.com 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.03 Jun Severely Injured Patients Do Better In High Level Trauma Centers
MedicalResearch.com Interview with:
Huiyun Xiang, M.D., M.P.H.
Center for Pediatric Trauma Research
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: In the United States trauma system, the most severe injuries ideally should receive definitive treatment at level I or level II trauma centers, while less severe injuries should receive treatment at level III or nontrauma centers. “Undertriage” occurs when a severe injury receives definitive treatment at a lower level trauma center instead of a level I or level II trauma center. But no study had used nationally representative data to evaluate mortality outcomes of undertriage at nontrauma centers.
Our study found detrimental consequences associated with undertriage at nontrauma centers. There was a significant reduction in the odds of emergency department (ED) death – by approximately half – in severely injured trauma patients who were properly triaged to a level I or level II trauma center versus those who were undertriaged to a nontrauma center. We also found that patients with moderate injuries may not have a reduction in the odds of ED death when triaged to a level I or level II trauma center instead of a nontrauma center. That suggests a possible threshold of injury severity when triaging trauma patients.
29 May Smoking, Addiction and Mental Health Issues Linked To Frequent Emergency Department Visit
MedicalResearch.com Interview with:
Jessica Castner, PhD, RN, CEN
Assistant Professor
University at Buffalo, New York
Medical Research: What is the background for this study?
Dr. Castner: There are groups of people more likely to visit the emergency department (ED) frequently. One of these groups are people insured by Medicaid, the insurance for those with low incomes. By finding what factors increase the risk for frequent emergency department use, healthcare leaders can target interventions to design a more effective and accessible healthcare delivery system. With approximately 12 million ED visits each year related to behavioral health issues, we wanted to investigate how smoking, substance abuse and psychiatric diagnoses increased the risk for repeat ED use for adults insured by Medicaid.
There are many problems associated with frequent emergency department use, including less than ideal continuity of care, crowding, and cost. Every year, there are over 136 million visits to United States EDs, and 12 million are linked to some sort of behavioral health issue. Unlike primary care, the patient is not likely to see a healthcare provider in the emergency department who knows them or one who may not have access to their complete and up-to-date records. The patient might get conflicting guidance or have tests ordered that duplicate tests recently done in other settings.
Frequent emergency department visitors also contribute to crowded EDs, where demand outstrips capacity. Studies have shown an association with increased morbidity and mortality for patients treated in the ED during these times of crowding.
Medical Research: What are the main findings?
Dr. Castner: The main findings of our study include helping to dispel the myth of “inappropriate emergency department use.” Our research analyzed the 2009 Medicaid claims for Erie and Niagara County. Our findings indicate that there is a positive relationship between outpatient visits and frequent emergency department use. In other words, people who are sicker and have more complex illnesses use all services more – both the emergency department and their outpatient care provider. In addition, we found that smoking, substance abuse, and psychiatric diagnoses all substantially increased the odds of frequent emergency department use – or ED bouncebacks. The most surprising finding was that healthy individuals were four times more likely to be frequent ED users if they smoked.
18 May Low Risk Of Adverse Cardiac Events in Patients With Negative ER Evaluation For Chest Pain
MedicalResearch.com Interview with:
Michael B. Weinstock, MD
Professor of Emergency Medicine, Adjunct
Department of Emergency Medicine, The Ohio State University College of Medicine
Emergency Department Chairman and Director of Medical Education, Mt. Carmel St. Ann's Dept. of Emergency Medicine
Columbus, Ohio
Medical Research: What is the background for this study?
Response: Patients with potential cardiac ischemia are often admitted to the hospital even after a negative evaluation in the emergency department due to concern about missed MI, unstable angina, or potential for cardiac arrhythmia.
Medical Research: What are the main findings?
Response: Our study was different than previous studies and clinical decision rules; instead of looking at a 30 day marker, which is important to the cardiologist, ours looked at the risk of a Clinically Relevant Adverse Cardiac Event (CRACE) occurring during hospitalization. These events included inpatient STEMI, life-threatening arrhythmia, cardiac or respiratory arrest, or death. The study found only 4 of these events out of 7266 patients studied and of the 4, two were possibly iatrogenic, suggesting that after a negative ED evaluation (including 2 negative serial cardiac enzyme tests, non-ischemic and interpretable ECG, and nonconcerning vital signs) a patient can be safely sent home for an expedited cardiac outpatient evaluation.
13 May Frequent ER Visits Linked To Prescription Drug Overdose
MedicalResearch.com Interview with: Joanne Brady, PhD candidate Department of Anesthesiology, College of Physicians and Surgeons Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY Medical Research: What is the background for this study? What are the main findings? Response: Prescription drug overdose is a major public health problem in the United States. Prescription drug overdose mortality has increased dramatically over the past twenty five years. Frequent emergency department utilization may be a marker for risk of prescription drug overdose death. The current study assessed how frequency of emergency department visits in the past year related to risk of subsequent prescription drug overdose death. In a cohort of patients visiting the emergency department, patients with four or more visits to the emergency department in the past year were at substantially higher risk for prescription drug overdose death than patients who visited the emergency department one or fewer times. As the number of visits to the emergency department increased from 0 - 1 to 4 or more for any reason the risk of dying from prescription drug overdose also increased.11 May Frequent Emergency Department Users More Likely To Die Or Be Admitted
MedicalResearch.com Interview with:
Dr. Brian Rowe, MD, MSc, CCFP(EM), FCCP
Professor, Department of Emergency Medicine
University of Alberta, Edmonton, Alberta, Canada
MedicalResearch: What is the background for this study?
Dr. Rowe: Frequent users are also called “familiar faces” or “heavy users” and they represent an important sub-group of patients in the emergency setting, with often complex needs that contribute to overcrowding and excess health care costs. The evidence suggests that frequent users account for up to one in 12 patients seeking emergency care, and for around one in four of all visits.
MedicalResearch: What are the main findings?
Dr. Rowe: Frequent users of emergency department care are more than twice as likely to die, be admitted to hospital, or require other outpatient treatment as infrequent users, concludes an analysis of the available evidence, published in Emergency Medicine Journal.
These conclusions are based on a thorough search of seven electronic databases of relevant research relating to the frequency and outcomes of emergency department use by adults. Out of a total of more than 4000 potential studies, 31 relevant research reports published between 1990 and 2013 were included in the final analysis. Frequent users were variably defined as visiting emergency care departments from four or more times up to 20 times a year.
Among the seven studies looking at deaths, the analysis showed that frequent attenders at emergency care departments were more than twice as likely to die as those who rarely sought emergency care. Most of the studies included hospital admission as an outcome, and these showed that frequent users were around 2.5 times as likely to be admitted as infrequent users. Ten studies looked at use of other hospital outpatient care, and these showed that frequent users were more than 2.5 times as likely to require at least one outpatient clinic after their visit to the emergency care department.
07 May Connecting Chronically Ill Patients To Safety Net Clinics Reduced ER Visits
MedicalResearch.com Interview with:
Karoline Mortensen, Ph.D.
Assistant Professor
Department of Health Services Administration
University of Maryland
College Park, MD
Medical Research: What is the background for this study?
Dr. Mortensen: For twenty years, use of hospital emergency departments has been on the rise in the United States, particularly among low-income patients who face barriers to accessing health care outside of hospitals including not having an identifiable primary health care provider. Almost half of emergency room visits are considered “avoidable.” The Emergency Department-Primary Care Connect Initiative of the Primary Care Coalition, which ran from 2009 through 2011, linked low-income uninsured and Medicaid patients to safety-net health clinics.
Medical Research: What are the main findings?
Dr. Mortensen: “Our study found that uninsured patients with chronic health issues – such as those suffering from hypertension, diabetes, asthma, COPD, congestive heart failure, depression or anxiety – relied less on the emergency department after they were linked to a local health clinic for ongoing care,” says Dr. Karoline Mortensen, assistant professor of health services administration at the University of Maryland School of Public Health and senior researcher. “Connecting patients to primary care and expanding the availability of these safety-net clinics could reduce emergency department visits and provide better continuity of care for vulnerable populations.”
07 May Emergency Room Coding Of Heart Failure Diagnosis Validated
MedicalResearch.com Interview with:
Justin A. Ezekowitz, MBBCh MSc
Associate Professor, University of Alberta
Co-Director, Canadian VIGOUR Centre
Director, Heart Function Clinic
Cardiologist, Mazankowski Alberta Heart Institute
Medical Research: What is the background for this study?
Dr. Ezekowitz: Heart Failure is a prevalent health issue that carries high morbidity and mortality. Most epidemiologic research derives information from hospital discharge abstracts, but emergency department visits are another source of information. Many have assumed this code is accurate in the emergency department but uncertainty remains.
In our study, we assessed patients at their presentation to Emergency Department, which is usually the first medical contact for acutely ill patients with heart failure.
The objective of our study was to compare administrative codes for acute heart failure (I50.x) in the emergency department against a gold standard of clinician adjudication.
Medical Research: What are the main findings?
Dr. Ezekowitz: Emergency department administrative data is highly correlated with a clinician adjudicated diagnosis. The positive predictive value of acute heart failure as the main diagnosis was 93.3% when compared to clinician adjudication, supported by standardized scoring systems and elevated BNP.
21 Apr World Trade Center Emergency Workers At High Risk Of Health Conditions
MedicalResearch.com Interview with:
Dr Mayris P Webber Dr.PH. MPH
Bureau of Health Services Fire Department of the City of New York Brooklyn, NY
Professor of Clinical Epidemiology & Population Health
Montefiore Medical Center NY
Medical Research: What is the background for this study? What are the main findings?
Dr. Webber:
- To date, we and others have found adverse health outcomes associated with World Trade Center (WTC) exposure among New York City’s first responders such as firefighters, police officers, and other rescue and recovery workers. We conducted the first study to concentrate on the health impact of the disaster on emergency medical service (EMS) workers.
- In keeping with previous research on WTC’s first responders, we found that the WTC attacks adversely affected the physical and mental health of approximately 2,000 New York City Fire Department (FDNY) EMS who performed rescue and recovery work at the site.
- We analyzed selected physical and mental health conditions that have been certified as being linked to the aftermath of the WTC attacks under the James Zadroga 9/11 Health and Compensation Act of 2010.
- Over a 12 year period, between September 11 2001 and December 31 2013, the proportion of newly diagnosed cases of gastroesophageal reflux disease (GERD) was 12.1%; obstructive airways disease (OAD) 11.8%; rhinosinusitis 10.6%; and cancer 3.1%.
- In their most recent mental health survey, nearly 17% of EMS workers reported symptoms consistent with depression; 7% with post-traumatic stress disorder (PTSD); and 3% with harmful alcohol use.
- Compared with EMS workers who did not work at the WTC site, EMS workers who worked at the WTC site in the morning of 9/11 (i.e., most intensely exposed) were at greatest risk for nearly all of the health conditions analyzed.
- For example, they were almost four times as likely to have GERD and rhinosinusitis, seven times as likely to have probable PTSD, and twice as likely to have probable depression. (We use the term probable because we used screening questionnaires instead of professional diagnoses for these mental health conditions).
14 Apr High Cost-Sharing Policies For Physician Care May Not Benefit Chronically Ill Patients
MedicalResearch.com Interview with:
Haichang Xin, PhD
Department of Health Care Organization and policy
School of Public Health
University of Alabama at Birmingham
MedicalResearch: What is the background for this study?
Dr. Xin: Since high cost-sharing policies can reduce both needed care and unneeded care use, it raises the concern whether these policies are a good strategy for controlling costs among chronically ill patients, especially whether utilization and costs in emergency department (ED) service and inpatient care will increase in response. Moreover, the costs saved by reduced physician care may be offset or even exceeded by the increased ED or inpatient care expenditures, causing a total cost increase for health plans.
This study was the first to examine whether high cost-sharing policies for physician care are associated with a differential impact on total care costs between chronically ill individuals and healthy individuals. Total care includes physician care, ED service and inpatient care.
MedicalResearch: What are the main findings?
Dr. Xin: Chronically ill individuals’ probability of reducing any overall care costs was significantly less than healthier individuals (β= 2.18, p = 0.04), while the integrated Difference-in-difference estimator from split results in the two-part model indicated that going from low cost-sharing to high cost-sharing significantly reduced costs by $12,853.23 more for sick people than for healthy people (95% CI: -$17,582.86, -$8,123.60).
09 Apr Reducing Emergency Department Costs By Improving Ambulatory Care
MedicalResearch.com Interview with:
Haichang Xin, PhD
Department of Health Care Organization and policy
School of Public Health
University of Alabama at Birmingham
MedicalResearch: What is the background for this study?
Dr. Xin: Research suggests that nearly half of all emergency department (ED) visits in the United States are for nonurgent conditions, leading to billions of dollars in potentially avoidable spending annually. A well-functioning primary care system has the capacity to provide timely, adequate, and effective care for patients in order to avoid nonurgent emergency department use and care costs.
This study examined how deficiencies in ambulatory care were associated with nonurgent emergency department care costs nationwide, and to what extent these costs can be reduced if deficiencies in primary care systems could be improved.
MedicalResearch: What are the main findings?
Dr. Xin: Patient perceived poor and intermediate levels of primary care quality had higher odds of nonurgent emergency department care costs (OR=2.22, p=0.035, and OR=2.05, p=0.011, respectively) compared to high quality care, with a marginal effect (at means) of 13.0% and 11.5% higher predicted probability of nonurgent ED care costs.
These ambulatory care quality deficiency related costs amounted up to $229 million for private plans (95% CI: $100 million, $358 million), $58.5 million for public plans (95% CI: $33.9 million, $83.1 million), and an overall of $379 million (95% CI: $229 million, $529 million) at the national level.