How Much Non-Invasive Testing Is Necessary In ER To Rule Out Heart Attack?

MedicalResearch.com Interview with:

David L. Brown, MD, FACC Professor of Medicine Cardiovascular Division Washington University School of Medicine St. Louis, MO 63110

Dr. Brown

David L. Brown, MD, FACC
Professor of Medicine
Cardiovascular Division
Washington University School of Medicine
St. Louis, MO 63110

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Approximately 10 million patients present to emergency rooms in the US annually for evaluation of acute chest pain.

The goal of that evaluation is to rule out the diagnosis of an acute heart attack. Imaging with coronary CT angiography and stress testing are not part of the diagnostic algorithm for acute heart attack.  Nevertheless many chest pain patients undergo some form of noninvasive cardiac testing in the ER. We found that CCTA or stress testing adding nothing to the care of chest pain patients beyond what is achieved by a history, physical examination, ECG and troponin test.

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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.

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CT Scanner in Emergency Room Improves ER Efficiency

Ania Z. Kielar, MD, FRCPC Department of Radiology at the University of Ottawa The Ottawa Hospital, Ottawa, Ontario,CanadaMedicalResearch.com Interview with:
Ania Z. Kielar, MD, FRCPC
Department of Radiology at the University of Ottawa
The Ottawa Hospital, Ottawa, Ontario,Canada

Medical Research: What is the background for this study? What are the main findings?

Dr. Kielar: One of the goals of imaging is to provide homogeneous and consistent, high-quality care for patients using available equipment.  In our hospital system, we had two separate hospitals that merged to form one teaching centre over 15 years ago.  Most processes and protocols are same between the two hospital sites as a result of having the same administration and the same University affiliation. Also,  the same residents and staff  rotate through the emergency departments and radiology departments at both hospitals.  One variable that persists is the location of the CT scanner.  At one center a space was created to place a CT scanner in the Emergency Department. At the other site, the CT scanner is in the radiology department.  For non-trauma cases, we wanted to see if the difference in distance of the scanner with respect to  the emergency department location, has a role in the time required to obtain CT scan from the time it is requested ,as well as the time to final patient disposition. We defined final patient disposition to include admission, subspecialty consultation or discharge home.

Medical Research: What are the main findings?

Dr. Kielar:  We found that there was a statistically significant difference in the time between requested CT and time to completion of the CT between the two hospital sites. It was faster when the CT scanner was located in the emergency department.  This was in the range of 16 minutes ,which is longer than simply the time required to walk over (and back) to the the CT scanner from the emergency department.

We also found a statistically significant difference in the time of the final patient disposition.  Of note, there was no statistically significant difference noted in the time to obtain a CT scan as well as the preliminary radiology interpretation for patients with hyperacute conditions such as suspected abdominal aortic aneurysm rupture, regardless of the location of the CT scanner with respect to the ED.

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Perspective on ER Residents Work Hour Regulations

Catherine A. Marco, MD, FACEP Professor Department of Emergency Medicine Wright State University Kettering, OH 45429MedicalResearch.com Interview with:
Catherine A. Marco, MD, FACEP Professor
Department of Emergency Medicine
Wright State University
Kettering, OH 45429

Medical Research: What is the background for this study? What are the main findings?

Dr. Marco: In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented standards on duty hours and supervision. A maximum of 80 hours of duty per week were stipulated.  The aim of these standards was to promote resident learning and patient safety.  However, evidence has not clearly demonstrated whether the 2003 requirements improved trainee well-being or patient safety.    On July 1, 2011, the ACGME implemented additional regulations on duty hours and supervision, including a 16 hour maximum shift length for PGY1 residents. The duty hours standards were implemented to ensure patient safety and provide an excellent teaching environment.  Emergency Medicine has additional duty hours requirements for emergency department rotations, including a maximum of 12 continuous scheduled hours, and a maximum 60 scheduled hours per week seeing patients in the emergency department, and no more than 72 duty hours per week.

We found that among a large cohort of 4134 Emergency Medicine residents, the majority of residents stated that they are working the appropriate number of hours to practice independently at graduation.  The majority of residents believe that current duty hours regulations improve patient safety.  The majority of residents agreed that duty hour regulations are currently appropriate.

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Malpractice Reform Did Not Change ER Doctor Habits or ER Costs

Daniel A. Waxman, MD, PhD Department of Emergency Medicine David Geffen School of Medicine University of California, Los Angeles RAND Corporation Santa Monica, CaliforniaMedicalResearch.com 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, California

Medical Research: What are the main findings of the study?

Dr. Waxman: About 10 years ago, three states (Texas, Georgia, and South Carolina) passed laws which made it much harder for doctors to be sued for malpractice related to emergency room care.   The goal of our research was to determine whether the lower risk of being sued translated into less costly care by emergency physicians.  To figure this out, we looked at the billing records of nearly 4 million Medicare patients and compared care before and after the laws took effect, and between states that passed reform and neighboring states that didn’t change their laws.   We found that these substantial legal protections didn’t cause ER doctors to admit fewer patients to the hospital, to order fewer CT or MRI scans, or to spend less for the overall ER visit.
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Emergency Room Screening for Delirium

Dr. Michael A. LaMantia Regenstrief Institute, Inc. Investigator and Assistant Professor of Medicine Indiana University School of MedicineMedicalResearch.com Interview with:
Dr. Michael A. LaMantia
Regenstrief Institute, Inc. Investigator and
Assistant Professor of Medicine
Indiana University School of Medicine

MedicalResearch.com: What are the main findings of the study?

Dr. LaMantia: We conducted a systematic review of existing studies on delirium in emergency departments and found that neither completely validated delirium screening instruments nor an ideal schedule to perform delirium assessments exist there.
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Children’s Health Insurance Program: Expansion did not reduce ER Use

Adrianne Haggins, MD, MS University of Michigan Health System Department of Emergency Medicine Ann Arbor, MI  48109-5303MedicalResearch.com Interview with:
Adrianne Haggins, MD, MS
University of Michigan Health System
Department of Emergency Medicine
Ann Arbor, MI  48109-5303


MedicalResearch.com: What are the main findings of the study?

Dr. Haggins: Since the implementation of the Children’s Health Insurance Program (CHIP) in 1997, the last national health care reform that broadly expanded insurance coverage, adolescent use of primary care and specialty care has increased substantially in comparison to no change seen among the comparison group (young adults, who were not covered).  Broadening insurance coverage for adolescents did not result in a decrease in emergency department use, while ED use in the comparison group increased over time.   Continue reading

Effects of obesity on patient experience in the emergency department

MedicalResearch.com eInterview with Professor David McDonald Taylor
Emergency Department, Austin Health
PO Box 5555, Heidelberg, Vic. 3084, Australia

MedicalResearch.com: What are the main findings of the study?

Answer: Overall, obese and non-obese patients have similar experiences during their ED stay. However, while obese patients tend to be younger and less sick, their more frequent presentation with potentially cardiac-related disease is reflected in their management. The excess of liver function tests and abdominal xrays performed on obese patients is likely to reflect examination difficulties and over investigation. Obese patients do experience more attempts at IV cannulation.
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