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High Spending EDs Provide Better Care, Save Lives

CAMBRIDGE, MA – Emergency physicians have argued the case for years: The emergency department is not the place to cut back healthcare spending. Now, a new study from the Massachusetts Institute of Technology agrees with them.

The report, published recently in the Journal of Political Economy, finds that patients who are brought by ambulance to higher-cost hospitals achieve better outcomes.

“If the question is, ‘Do high-spending hospitals get better outcomes for emergency care?’ we think that they do,” said co-author Joseph Doyle, PhD, an MIT economist. “We do find that if you go from a low-spending hospital to a high-spending hospital, you get significantly lower mortality rates.”

Using Medicare data from 2002–10, the National Institutes of Health-funded study finds that increasing emergency-care spending by one standard deviation above the mean generates roughly a 10% reduction in mortality.

“People have concluded from previous research that there must be huge waste in the [medical] system,” Doyle said. “At a bare minimum, our research suggests more caution in that interpretation.”

For the investigation, researchers assessed ambulance-dispatch patterns in New York state to determine how similar groups of patients fare when given varying amounts of treatment at different price points.

The study examined patients with 29 types of serious conditions in 40 communities, and used Medicare billing data to see what medical services were provided to them.

The authors note that ambulances are essentially randomly assigned to patients in the same area based on rotational dispatch mechanisms, which affects hospital choice for patients in the same ZIP code. Using data for New York state from 2000-06 that matches exact patient addresses to hospital discharge records, the researchers show that patients who live very near each other but on either side of ambulance-dispatch boundaries can go to different types of hospitals.

Results indicate that higher-cost hospitals have significantly lower one-year mortality rates compared to lower-cost hospitals. Assuming the cost per one year of a life saved is about $80,000, the study found that teaching hospitals and those which are early adopters of the latest technology had the best outcomes, as well as those with higher treatment intensity, according to the report.

The study cautions that, at some point, there are diminishing returns to hospital spending and treatment intensity but that point was not yet reached in this research.

 “If we’re trying to find out where the waste is, our research suggests it’s not in emergency care,” Doyle emphasized.



Endovascular Treatment Could Change How EDs Manage Stroke CasesELB for ED Push

CALGARY, ALBERTA – New research holds the promise of changing how acute ischemic stroke is treated.

The ESCAPE (Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times) trial indicates that endovascular treatment (ET), can dramatically improve patient outcomes after an acute ischemic stroke. In fact, the trial was stopped early because of efficacy.

Overall, positive outcomes for patients increased from 30% to 55% with the clot retrieval system, according to the study published online by the New England Journal of Medicine. The research also was presented at the American Heart Association's International Stroke Conference in Nashville earlier this month.

Instead of suffering major neurological disability, patients often were able to go home and resume their lives, according to the study led by researchers from the University of Calgary's Hotchkiss Brain Institute (HBI). The overall mortality rate was reduced 50% – from two in 10 patients for standard treatment of care to one in 10 patients with ET.

“Among patients with acute ischemic stroke with a proximal vessel occlusion, a small infarct core, and moderate-to-good collateral circulation, rapid endovascular treatment improved functional outcomes and reduced mortality,” the authors conclude.

“This is the most significant and fundamental change in acute ischemic stroke treatment in the last 20 years. These results will impact stroke care around the world," added senior author Michael Hill, MD, professor in the Cumming School of Medicine's departments of clinical neurosciences, and radiology and a neurologist with the Calgary Stroke Program of Alberta Health Services.

Currently, the international standard of care based on Canadian, U.S. and European guidelines is to administer tPA when appropriate to dissolve the blood clot.

In the ESCAPE trial, 316 patients who fit the criteria for ET and arrived for treatment within 12 hours of their stroke were randomized to standard medical care, including tPA administration where appropriate, or standard medical care plus ET.

Using an X-ray for image-guidance, ET is performed by inserting a thin tube into the artery in the groin, through the body, and into the brain vessels to the clot. The clot is then removed by a retrievable stent and pulled out, restoring blood flow to the brain.

Although endovascular treatments were first developed in the 1990s, ET has only recently been technically possible, partly because it requires very fast treatment and the use of brain and blood vessel imaging, according to the ESCAPE authors.

"Key reasons for the success of the trial were, firstly, selecting appropriate patients using novel imaging technology; secondly, better organization and workflow to expedite treatment; and thirdly, use of modern technology to open the blood vessels," said first author Mayank Goyal, MD, professor of radiology and clinical neurosciences at the Cumming School of Medicine and co-principal investigator of the ESCAPE trial. "We believe that with the combined results from this trial and other trials, this will become the standard of care."

ESCAPE is the second ET trial that demonstrates the efficacy of the treatment and the first trial to demonstrate reduced mortality. The previous trial, known as MR. CLEAN (Multi center Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands), was published in December 2014.

The current study included 22 sites worldwide and patients in the U.S., U.K., Ireland and South Korea. Canada had 11 participating hospitals and enrolled two-thirds of the patients.


New Study Recommends Balanced Transfusion for Severe Trauma Patients

S14170 - LLSA for ED PushHOUSTON – Giving severe trauma patients a transfusion with a balanced ratio of plasma, platelets, and red blood cells (RBCs) is more likely to stop severe bleeding and reduce the risk of death from blood loss over 24 hours than transfusing a higher ratio of RBCs, according to a new study.


Background in the article, published recently in the Journal of the American Medical Association, notes that about 20% to 40% percent of trauma deaths occurring after hospital admission involve extensive hemorrhage from an injury to the trunk of the body and are potentially preventable with rapid hemorrhage control and improved resuscitation techniques, including massive transfusion.

The authors, led by researchers from the University of Texas Health Science Center at Houston, add that earlier transfusion with balanced blood product ratios (1:1:1 ratios for plasma, platelets, and red blood cells) – dubbed "damage control resuscitation” – has been associated with improved outcomes. No large multicenter clinical trials had previously tested that supposition, however.

To determine the value of using a balanced transfusion, researchers focused on the cases of 680 severely injured patients who arrived at one of 12 level 1 trauma centers and were predicted to require massive transfusion. The patients were randomly assigned to receive blood product ratios of 1:1:1 for units of plasma to platelets to red blood cells – a ratio that is the closest approximation to reconstituted whole blood – or 1:1:2 during active resuscitation. The patients also received all local standard-of-care interventions.

Patients were assigned to one the component ratios within eight minutes of calling the blood bank to allow the rapid delivery and infusion of the predetermined ratios, according to the study.

No statistically significant differences for the primary outcomes of the study were found; mortality at 24 hours was 12.7% in the 1:1:1group vs. 17% in the 1:1:2 , while mortality at 30 days was 22.4% vs. 26.1%, respectively.

Exsanguination, the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group, 9.2% vs. 14.6% in the 1:1:2 group, however. In addition, more patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group – 86% vs. 78%.

The authors emphasize that, despite concerns that the 1:1:1 group would experience higher rates of multiple inflammatory-mediated complications such as acute respiratory distress syndrome, multiple organ failure, infection, blood clots, and sepsis, no such differences were detected between the two treatment groups.

"Given the lower percentage of deaths from exsanguination and our failure to find differences in safety, clinicians should consider using a 1:1:1 transfusion protocol, starting with the initial units transfused while patients are actively bleeding, and then transitioning to laboratory-guided treatment once hemorrhage control is achieved,” the researchers write. “Future studies of hemorrhage control products, devices, and interventions should concentrate on the physiologically relevant period of active bleeding after injury and use acute complications and later deaths (24 hours and 30 days) as safety end points.”


Intravenous Migraine Therapy Relieves Post-Traumatic Headaches in Children

CINCINNATI – Intravenous migraine therapy reduces post-traumatic headache (PTH) scores for children presenting to the emergency department within 14 days after suffering a mild traumatic brain injury (mTBI), according to a new study.

Whether the treatment has long-term benefits, however, is yet to be determined, according to the research printed recently in the American Journal of Emergency Medicine.

Background in the article notes that more than 3.8 million children sustain brain injuries annually, but that treatment of PTH in the ED varies and the benefits have been unclear.

To clarify the issue, researchers from the Cincinnati Children's Hospital Medical Center sought to determine if intravenous migraine therapy reduces pain scores in children with PTH as well as other factors associated with improved response.

For the retrospective study, the researchers looked at children, 8 to 21 years old, who presented to a tertiary pediatric ED with mTBI and PTH from November 2009 to June 2013. Included in the study were children who had an mTBI defined by diagnosis code within 14 days of the ED visit, headache, and administration of one or more intravenous medications: ketorolac, prochlorperazine, metoclopramide, chlorpromazine, and ondansetron.

With the primary outcome defined as a pain score reduction greater or equal to 50% during the ED visit, the researchers also analyzed potential predictors of treatment success, including age, sex, migraine or mTBI history, time since injury, ED head computed tomographic (CT) imaging, and pretreatment with oral analgesics.

The 254 patients included in the study had a mean age of 13.8 years and were 51% female and 80% white. Mean time since injury was two days, and 114 of the patients had negative head CTs.

Results indicate that 86% of patients had treatment success with intravenous migraine therapy; 52% experienced complete resolution of headache. Patients who had a head CT were less likely to respond – 80% vs 91%.

“Intravenous migraine therapy reduces PTH pain scores for children presenting within 14 days after mTBI,” the authors conclude. “Further prospective work is needed to determine long-term benefits of acute PTH treatment in the ED.”