Author Interviews, Electronic Records, Emergency Care, JAMA / 19.09.2019 Interview with: Carl Berdahl, MD, MS Emergency Physician and Health Services Researcher CEDARS-SINAI West Hollywood CA What is the background for this study? Response: The length of a doctor’s note is taken account when determining how much a doctor or medical center is paid for a visit. However, in the digital era, a doctor can generate large amounts of text with just a few keystrokes. Given this incentive structure, we were concerned doctors’ notes might be inaccurate in certain sections of the chart that are important for billing. We used observers to determine how accurately doctors’ notes reflected the interactions between patients and physicians. (more…)
Author Interviews, Biomarkers, Brain Injury, Emergency Care, Pediatrics / 31.08.2019 Interview with: Linda Papa, MD Emergency Physicians of Central Florida Orlando Health Orlando, Florida What is the background for this study? Response: In 2018 serum biomarkers Glial Fibrillary Acidic Protein (GFAP) and Ubiquitin C-terminal hydrolase (UCH-L1) were FDA-approved in adults to detect abnormalities on CT scan in mild to moderate traumatic brain injury. However, they have not been approved to detect concussion and they have not been approved for use in children. Previous studies have focused on detecting lesions on CT in more severely injured patients. However, not having brain lesions on a CT scan does not mean there is no brain injury or concussion. Therefore, this study focused on patients with concussion who looked well and likely had normal-appearing CT scans of the brain. This study includes THREE groups of trauma patients:
  • 1) those with concussion,
  • 2) those who hit their head but had no symptoms (subconcussive), and
  • 3) those who injured their bones but did not hit their head (no concussion).
There is a group of individuals with head trauma who have been significantly understudied, and in whom biomarkers are rarely, if at all, examined. These are people who experience head trauma without symptoms of concussion. They may be classified as having “no injury” or they may represent milder forms of concussion that do not elicit the typical signs or symptoms associated with concussion and are referred to as “subconcussive” injuries.  (more…)
Alcohol, Author Interviews, CMAJ, Emergency Care / 22.07.2019 Interview with: Daniel Myran, MD, MPH, CCFP Public Health & Preventive Medicine, PGY-5 University of Ottawa What is the background for this study? Response: We know that alcohol consumption results in enormous health and societal harms globally and in Canada. While several studies have looked at changes in alcohol harms, such as Emergency Department (ED) visits and Hospitalizations due alcohol, this study is the first to examine in detail how harms related to alcohol have been changing over time in Canada. (more…)
Author Interviews, Emergency Care, Mental Health Research, Psychological Science / 03.06.2019 Interview with: Stephen L. Ristvedt, Ph.D. Associate Professor of Anesthesiology Washington University St. Louis, MO  63110-1093 What is the background for this study? Response: Having a usual source of healthcare – either with a regular doctor or a medical clinic – is the best way to manage one’s health in a proactive way.  Doctors and clinics can provide ongoing guidance with regard to the use of preventive medical screenings as well as the management of chronic illness.  Unfortunately, a significant proportion of US adults do not have a usual source of healthcare.  Also, many people often rely for their healthcare needs on a hospital emergency department, where there is neither sufficient continuity of care nor counseling for prevention. We wanted to investigate what factors might contribute to suboptimal utilization of healthcare resources.  We were particularly interested in looking at individual psychological factors that might play a role in the choices that people make when seeking healthcare.  One specific psychological characteristic proved to be important in our study.  That characteristic is called “threat sensitivity,” and it is measured with a simple questionnaire.  People who are relatively high in threat sensitivity are prone to experience high levels of anxiety in potentially threatening situations  (more…)
Author Interviews, Cancer Research, CMAJ, Emergency Care / 29.04.2019 Interview with: Keerat Grewal, MD, MSc, FRCPC Schwartz/Reisman Emergency Medicine Institute Mount Sinai Hospital Toronto, ON What is the background for this study? What are the main findings?  Response: Patients with cancer have complex care requirements and often use the emergency department. The purpose of our study was to determine whether continuity of care, cancer expertise, or both, impact outcomes among cancer patients in the emergency setting. Using administrative data we looked at adult patients with cancer who received chemotherapy or radiation therapy in the 30 days prior to an emergency department visit.  (more…)
Author Interviews, Emergency Care, Gastrointestinal Disease, Pediatrics / 15.04.2019 Interview with: Danielle Orsagh-Yentis, MD Pediatric GI Motility Fellow Department of Gastroenterology, Hepatology and Nutrition Nationwide Children’s Hospital Columbus, Ohio What is the background for this study? Response: Foreign body ingestions are quite common in young children. Much of the literature and advocacy to date has focused on the harms of button battery and magnet ingestions. We found that foreign body ingestions in children younger than 6 years of age have been increasing over the past 2 decades. This overall increase is mirrored by the rise in coin, toy, and jewelry ingestions, as well as batteries, which, when swallowed, have the potential to cause considerable harm.  (more…)
Author Interviews, Brain Injury, CT Scanning, Emergency Care, JAMA, Pediatrics / 24.09.2018 Interview with: Erik P. Hess MD MSc Professor and Vice Chair for Research Department of Emergency Medicine UAB Medicine he University of Alabama at Birmingham Birmingham Alabama 35249 What is the background for this study? What are the main findings?  Response: 450,000 children present to U.S emergency departments each year for evaluation of head trauma.  Physicians obtain head computed tomography (CT) scans in 37%-50% of these patients, with less than 10% showing evidence of traumatic brain injury and only 0.2% that require neurosurgical treatment. In order to avoid unnecessary CT scans and to limit radiation exposure, the Pediatric Emergency Care Applied Research Network (PECARN) developed clinical prediction rules that consist of 6 readily available factors that can be assessed from the history and physical examination.  If none of these risk factors are present, a CT scan is not indicated. If either of 2 high risk factors such as signs of a skull fracture are present, CT scanning is indicated. If 1 or 2 non-high risk factors are present, then either CT scanning or observation are recommended, depending on considerations such as parental preference, clinician experience and/or symptom progression. In this study we designed a parent decision aid, “Head CT Choice” to educate the parent about the difference between a concussion – which does not show up on a CT scan – and a more serious brain injury causing bleeding in or around the brain.  The decision aid also shows parents their child’s risk for a serious brain injury – less than 1% risk in the majority of patients in our trial – what to observe their child at home for should they opt not to obtain a CT scan, and the advantages and disadvantages of CT scanning versus home observation. In our trial, we did not observe a difference in the rate of head CT scans obtained in the ED but did find that parents who were engaged in shared decision-making using Head CT Choice were more knowledgeable about their child’s risk for serious brain injury, has less difficulty making the decision because they were clearer about the advantages and disadvantages of the diagnostic options, and were more involved in decision-making by their physician.  Parents also less frequently sought additional testing for their child within 1 week of the emergency department visit. (more…)
Author Interviews, Emergency Care, Neurology, Stroke / 13.07.2018 Interview with: Perttu JLindsberg, MD, PhD Professor of Neurology Clinical Neurosciences and Molecular Neurology Research Programs Unit, Biomedicum Helsinki University of Helsinki Helsinki, Finland What is the background for this study? Response: The past 20 years in shaping the Helsinki model in stroke thrombolysis have proven that we can be very fast in examining the patient, completing the imaging and starting thrombolytic therapy. This is a university hospital center that receives roughly three stroke suspects per day for evaluation of recanalization therapies. Already seven years ago we were able to push the median ’door-to-needle’ time permanently below 20 minutes. What we had not been monitoring was how well we had kept up the accuracy of our emergengy department (ED) diagnostic process. Prehospital emergency medical services (EMS) have been trained to focus on suspecting thrombolysis-eligible stroke and we usually get also pre-notifications of arriving stroke code patients during transportation, but the diagnosis on admission is an independent clinical judgment as the CT findings are largely nondiagnostic for acute changes. The admission evaluation of suspected acute stroke is therefore a decisive neurologic checkpoint, building the success of acute treatments such as recanalization therapy, but is complicated by differential diagnosis between true manifestations of stroke and numerous mimicking conditions. Although we have invested a lot on training and standardized ED procedures, time pressure and therapy-geared expectations may blur the diagnostic process. With this background, we embarked on an in-depth-analysis of the admission and final diagnoses of stroke code patients, as well as misdiagnoses, immediate treatment decisions and their consequences. (more…)
Accidents & Violence, Author Interviews, Emergency Care, Pediatrics / 27.06.2018 Interview with: “Bikes” by Britta Frahm is licensed under CC BY 2.0Lara McKenzie, PhD Principal investigator in the Center for Injury Research and Polic Nationwide Children’s Hospital. What is the background for this study? What are the main findings? Response: Bicycling is a great way for families to get outside and be active together, but certain precautions need to be taken to keep everyone safer. This study looked at bicycle-related injuries among children age 5-17 years treated in hospital emergency departments in the United States from 2006 through 2015 and found that, despite a decrease in the rate of injuries over the 10-year study period, there were still more than 2.2 million injuries. This averages 608 cases per day or 25 every hour. The majority of injuries involved children 10 to 14 years of age (46%) and boys (72%). The most commonly injured body region was the upper extremities (36%), followed by the lower extremities (25%), face (15%), and head and neck (15%). The most common types of injury were bruises and scrapes (29%) and cuts (23%). Overall, traumatic brain injuries (TBIs) represented 11% of total injuries and were most common among patients 10-14 years of age (44%). About 4% of patients were hospitalized. Injuries most frequently occurred in the street (48%) or at home (37%). Helmet use at the time of injury was associated with a lower likelihood of head and neck injuries and hospitalizations, but there was no significant change in the rate of injury among helmet users over the study period. Motor vehicle involvement increased the odds of bicycle-related TBIs and injury-related hospitalizations.  (more…)
Author Interviews, Emergency Care, Heart Disease, JACC, Medical Imaging / 21.06.2018 Interview with: Jeffrey M. Levsky, M.D., Ph.D. Associate Professor, Department of Radiology Associate Professor, Department of Medicine (Cardiology) Albert Einstein College of Medicine Montefiore Medical Center What is the background for this study? What are the main findings? Response: Millions of Americans are evaluated each year for acute chest pain in the Emergency Department.  There are multiple modalities that can be used to triage these patients and there have only been a few studies comparing different imaging methods. We chose to study Stress Echocardiography and Coronary CT Angiography, two exams that have not been compared directly in this population.  We found that Stress Echocardiography was able to discharge a higher proportion of patients in a shorter amount of time as compared to Coronary CTA.  (more…)
Author Interviews, JAMA, Outcomes & Safety, Race/Ethnic Diversity, Surgical Research / 03.05.2018 Interview with: Dr-Hillary-J-Mull Hillary J. Mull, PhD, MPP Center for Healthcare Organization and Implementation Research Veterans Affairs (VA) Boston Healthcare System Department of Surgery, Boston University School of Medicine Boston, Massachusetts What is the background for this study? What are the main findings? Response: Little is known about outpatient procedures that can be considered invasive but are not conducted in a surgical operating room. These procedures are largely neglected by quality or patient safety surveillance programs, yet they are increasingly performed as technology improves and the U.S. population gets older. We assessed the rate of invasive procedures across five specialties, urology, podiatry, cardiology, interventional radiology and gastroenterology in the Veterans Health Administration between fiscal years 2012 and 2015. Our analysis included examining the rates of post procedure emergency department visits and hospitalizations within 14 days and the key patient, procedure or facility characteristics associated with these outcomes. We found varying rates of post procedure ED visits and hospitalizations across the specialties with podiatry accounting for a high volume of invasive outpatient care but the lowest rate of postoperative utilization (1.8%); in contrast, few of the procedures were in interventional radiology, but the postoperative utilization rate was the highest at 4.7%. In a series of logistic regression models predicting post procedure healthcare utilization for each specialty, we observed significantly higher odds of post procedural outcomes for African American patients compared to white patients. (more…)
Author Interviews, Emergency Care, Opiods / 08.04.2018 Interview with: Frank Scheuermeyer MD MHSc Clinical Associate Professor Department of Emergency Medicine St Paul’s Hospital and the University of British Columbia What is the background for this study? Response: Mortality from the opioid epidemic is dramatically increasing and a main culprit appears to be illicit fentanyl. Current research states that patients with presumed fentanyl overdoses are at high risk of deterioration and death, and require prolonged emergency department stays or hospital admission to ensure a safe outcome. Our inner-city hospital adopted a protocol initially developed for patients with heroin overdose, modified it to account for the greater potency of fentanyl, and studied 1009 consecutive patients who arrived with an overdose. (more…)
Author Interviews, Emergency Care, Heart Disease, JAMA / 26.02.2018 Interview with: Daniel A. Waxman, MD, PhD Department of Emergency Medicine David Geffen School of Medicine University of California, Los Angeles RAND Corporation Santa Monica, CaliforniaDaniel A. Waxman, MD, PhD Department of Emergency Medicine David Geffen School of Medicine University of California, Los Angeles RAND Corporation Santa Monica, California What is the background for this study? What are the main findings? Response: When people talk about medical error, they are usually referring to treatment error—giving the wrong medication, operating on the wrong side of the body, etc.  But many believe that diagnostic error—the failure to diagnose a condition when a patient seeks care—is at least as widespread and consequential a problem.  However, diagnostic errors are intrinsically difficult to measure, since one can rarely prove that a condition was present at the time it was not diagnosed. In this study, we introduce a novel method for measuring how often patients who come to the emergency room with symptoms of an imminent cardiovascular emergency such as acute myocardial infarction (heart attack) are discharged home without a diagnosis. We find that among Medicare patients whose ER visits were attributable to symptoms of an imminent infarction, only about 2.3% were discharged home, and that the figure was under 5% for each of the other four conditions we studied.    However, we also found that these relatively low rates did not improve between 2007 and 2014. (more…)
Author Interviews, Electronic Records, Emergency Care / 09.02.2018 Interview with: Shannon Toohey, MD, MAEd Associate Residency Director, Emergency Medicine Assistant Clinical Professor, Emergency Medicine University of California, Irvine Editor-in-Chief Journal of Education and Teaching in Emergency Medicine What is the background for this study? What are the main findings? Response: Electronic prescriptions (e-prescriptions) are now the predominant form of prescription used in the US. Concern has been raised that this form of prescription may be more difficult for emergency department (ED) patients to utilize than traditional printed prescriptions, given the unplanned nature of most ED visits at all times of day. While there are disincentives for physicians who choose not to use them, many emergency physicians are still concerned that it could decrease compliance in their patients. This study evaluated prescription compliance in insured patients at a single center. In our studied population, we found that patients were as equally likely to fill paper and e-Prescriptions. (more…)
Accidents & Violence, Author Interviews, CDC, Emergency Care, JAMA, Mental Health Research / 21.11.2017 Interview with:

Dr. Melissa C. Mercado PhD, MSc, MA Behavioral scientist Division of Violence Prevention National Center for Injury Prevention and Control CDC What is the background for this study? What are the main findings? Response: Suicide ranks as the 10th leading cause of death for all age groups combined and has been among the top 12 leading causes of death since 1975 in the U.S. In 2015, across all age groups, suicide was responsible for 44,193 deaths in the U.S., which is approximately one suicide every 12 minutes. Suicide was the second leading cause of death among U.S. youth aged 10-24 years in 2015. Self-inflicted injury is one of the strongest risk factors for suicide. This study examined trends in non-fatal self-inflicted injuries treated in hospital emergency departments (EDs) among youth aged 10 to 24 years in the United States from 2001-2015.  The overall weighted age-adjusted rate for this group increased by 5.7% annually during the 2008 to 2015 period.  Age-adjusted trends for males overall and across age groups remained stable throughout 2001-2015.  However, rates among females increased significantly, by 8.4% annually. The largest increase among females was observed among those aged 10-14 years, with an increase of 18.8% annually from 2009 to 2015. (more…)
Author Interviews, Emergency Care, Heart Disease, JAMA, Stanford / 27.06.2017 Interview with: Alexander Sandhu, MD MS Cardiology Fellow Stanford University What is the background for this study? What are the main findings? Response: Millions of patients present to the emergency department with chest pain but most do not have lab or EKG findings that indicate the patient is having a heart attack. In patients without signs of a heart attack, stress testing is frequently used to determine the need for further workup and treatment. However, there is limited evidence regarding the benefit of stress testing in these patients. We evaluated how cardiac testing - stress testing and coronary angiography - in these low-risk patients was associated with clinical outcomes. We used a statistical approach that took advantage of the fact that testing is more available on weekdays than weekends. We found that testing was associated with more angiography and revascularization (coronary stenting or coronary artery bypass surgery) but was not associated with a reduction in future heart attacks. (more…)
Author Interviews, Critical Care - Intensive Care - ICUs, Emergency Care, Infections, NEJM, University of Pittsburgh / 21.05.2017 Interview with: Christopher W. Seymour, M.D., M.Sc. Assistant professor of Critical Care Medicine and Emergency Medicine, and member of Clinical Research Investigation and Systems Modeling of Acute Illness University of Pittsburgh What is the background for this study? What are the main findings? Response: Following the tragic and widely publicized death of Rory Staunton, 12, from undiagnosed sepsis in 2012, New York became the first state to require that hospitals follow a protocol to quickly identify and treat the condition. The mandate led to widespread controversy in the medical community as to whether such steps would have saved Rory or anyone else’s life. Rory’s Regulations require hospitals to follow protocols for early identification and treatment of sepsis, and submit data on compliance and outcomes. The hospitals can tailor how they implement the protocols, but must include a blood culture to test for infection, measurement of blood lactate (a sign of tissue stress) and administration of antibiotics within three hours of diagnosis—collectively known as the “three-hour bundle.” We analyzed data from nearly 50,000 patients from 149 New York hospitals to scientifically determine if  Rory’s Regulations worked. We found that they did - 83 percent of the hospitals completed the bundle within the required three hours, overall averaging 1.3 hours for completion. For every hour that it took clinicians to complete the bundle, the odds of the patient dying increased by 4 percent. (more…)
Author Interviews, Critical Care - Intensive Care - ICUs, Emergency Care, Infections / 07.02.2017 Interview with: Anish Agarwal, MD, MPH The Hospital of the University of Pennsylvania Department of Emergency Medicine Philadelphia, PA What is the background for this study? What are the main findings? Response: The morbidity and mortality of severe sepsis has been well studied and documented. An aggressive approach to protocolized care for patients suffering from severe sepsis and septic shock has been shown to improve mortality and should be started as early in the time course of a patient's presentation. Emergency departments (ED) are designed to deliver time-sensitive therapies, however, they also may suffer from crowding due to multiple factors. This study aimed to assess the impact of ED crowding upon critical interventions in the treatment of severe sepsis including time to intravenous fluids, antibiotics, and overall delivery of a protocolized bundle of care. The study found that as ED crowding increased, time to critical therapies significantly increased and the overall implementation of procotolized care decreased. More specifically as ED occupancy and total patient hours within the ED increased, time to intravenous fluids decreased and time to antibiotics increased as occupancy, hours, and boarding increased. (more…)
Author Interviews, Critical Care - Intensive Care - ICUs, Emergency Care, Heart Disease, Kidney Disease / 21.11.2016 Interview with: Paul E Ronksley, PhD Assistant Professor Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary Canada What is the background for this study? Response: Prior studies have observed high resource use among patients with chronic kidney disease (CKD), which is related to the medical complexity of this patient population. However, there has been limited exploration of how patients with CKD use the emergency department (ED) and whether utilization is associated with disease severity. While the ED is essential for providing urgent or emergent care, identifying ways of improving ED efficiency and decreasing wait times has been recognized as a priority in multiple countries. Improving coordination and management of care for patients with multiple chronic conditions (the norm for CKD) in an outpatient setting may meet health care needs and ultimately improve patient experience and outcomes while reducing the burden currently placed on the ED. However, this requires an understanding of ED use among patients with CKD and the proportion of use that is amenable to outpatient care. Using a large population-based cohort we explored how rates of ED use vary by kidney disease severity and the proportion of these events that are potentially preventable by high quality ambulatory care. We identified all adults (≥18 years) with eGFR<60 mL/min/1.73m2 (including dialysis-dependent patients) in Alberta, Canada between April 1, 2010 and March 31, 2011. Patients with CKD were linked to administrative data to capture clinical characteristics and frequency of ED encounters, and followed until death or end of study (March 31, 2013). Within each CKD category we calculated adjusted rates of overall  emergency departmentt use, as well as rates of potentially preventable ED encounters (defined by 4 CKD-specific ambulatory care sensitive conditions (ACSCs); heart failure, hyperkalemia, volume overload, malignant hypertension). (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, 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, 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…)
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, 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…)
Accidents & Violence, Author Interviews, Emergency Care / 03.06.2015 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. (more…)
Author Interviews, Emergency Care, Nursing / 29.05.2015

Jessica Castner, PhD, RN, CEN Assistant Professor University at Buffalo, New 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. (more…)
Author Interviews, Cost of Health Care, Emergency Care, Primary Care / 09.04.2015

Haichang Xin, PhD Department of Health Care Organization and policy School of Public Health University of Alabama at 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. (more…)
Author Interviews, Emergency Care, Outcomes & Safety / 24.03.2015

Michael J. Beck MD, FAAP, SSGB Department of Pediatrics Milton S. Hershey Medical Center and the Pennsylvania State University College of Medicine, Hershey, Pennsylvania Interview with: Michael J. Beck MD, FAAP, SSGB Department of Pediatrics Milton S. Hershey Medical Center and the Pennsylvania State University College of Medicine, Hershey, Pennsylvania Medical Research: What is the background for this study? What are the main findings? Dr. Beck: Many hospitals are trying to improve patient discharge times. The benefits of this result will improve several valuable metrics within the organization’s value chain, namely improved access, reduced lost referrals, reduce emergency department boarding, to name a few. As our region’s only tertiary care children’s hospital, that serves an expanding demographics and geographic population, access to our facility is becoming both a priority and challenge. Since many hospitals and hence hospital service lines work with a fixed number of beds, serving a growing population is going to lead to or exacerbate hospital access issues and emergency department boarding. The latter of which may carry financial penalties in the future based on Joint Commission standard LD 04.03.01 (revised 2013). We sought to applying elements of Lean and constraint theory, which postulate that flow can be created by eliminating waste, and that a process can move only as fast as its scarcest resource, respectively. From a lean perspective, why should  “dischargeable” patients who were seen on AM work rounds still be occupying a valuable bed at 3 or 4PM when they were deemed safe for discharge hours earlier? Why should patients and organizations continue to tolerate this waste? Applying Lean thinking  forced our service to reconfigure, re-sequence, and re-staff rounds in a way that could better meet patients’ and our organization’s needs and requirements.  Since the discharge process output is an open bed, not having an open bed when it is needed, creates an organizational constraint. One constraint to creating an open bed, is the attending physician, ie a patient cannot be discharged until he/she is seen by the attending physician. However, another constraint is the model that one attending sees in excess of 13 patients per day (patient: provider ratio of 13:1). We hypothesized that by adding an attending  to reduce the  patient: provider ratio by 50% during predictable high volumes, we could do all of the discharge paperwork on rounds, at the time the decision to discharge is made by the attending.  By advancing discharge order entry time, we should be able to advance the time patients get discharged, create an open bed earlier in the day, and ultimately reduce lost referrals and emergency department boarding. Our service line median time of discharge order entry and time of patient discharge was compared to our own historical controls and to the same discharge behaviors of the remainder of our hospital services. The main intervention was staffing reallocation, creation of standard workflow expectations, and a discharge checklist. Finally, we also implemented a discharge huddle to occur before the day of anticipated day discharge. Over the 6 month intervention period, the median time of discharge entry decreased from 2:05PM to 10:45 AM and the median time of patient discharge decreased from 3:58PM to 2:15 PM.  The hospital  control group did not change from baseline. Our LOS went form 3.1 days to 3.0 days, and our 7, 14, and 30 day readmission rates did not increase. Emergency department boarding time was decreased by 30%, and lost referrals decreased 70% during the study period. (more…)