ED Push - March 2015 Second Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
How to Spot ‘Doctor-Shopping’ Patients Seeking Opioids at ED
BOSTON – If a white patient shows up at your emergency department during the weekend, complains of back pain and ask for medications by name, you have good reason to suspect “doctor shopping” for opioids and other controlled substances.
That’s according to a study published recently in the Journal of Emergency Medicine.Study authors, led by researchers from Tufts Medical Center in Boston, recommend that ED physicians use specific clinical characteristics to “identify high-risk patients and then target [them] for more in-depth counseling or screening” before writing a prescription.
To come up with the common characteristics, the research team reviewed records of 544 patients who had presented to two hospital EDs with a chief complaint of back pain, dental pain, or headaches. “Doctor-shoppers” were defined as patients who had prescriptions for Schedule II-V drugs filled from eight or more providers within one year.
About 12% were found to have doctor-shopping (DS) behavior and were more likely to request medications by name and to report allergies to non-narcotic medications than other patients, after accounting for gender, age, and race.
Of those patients, nearly 69% were white compared to 40.3% of patients not identified as doctor shopping. Back pain was more often the complaint than headache or dental pain, and patients were more likely to visit the emergency room on the weekend than other patients, the study found.
Results indicate that DS and non-DS patients were similar in sex but differed in age, race, chief complaint and weekday vs. weekend arrival. They also utilized a median of 12 providers compared to a median of one for the non-DS group.
“We propose that knowledge of these factors, in addition to utilization of screening tools, paying close attention to prior psychosocial factors that predispose to abuse and addiction, and routinely accessing [state Prescription Drug Monitoring Program data] . . . will lead to more informed prescribing of scheduled medications from the ED,” the authors write.
The researchers said the danger is taking the vigilance too far, which could result in undertreatment of pain in EDs.
“This situation creates a conundrum for clinicians working in the ED who need to both compassionately treat patients’ pain, but also steward the use of opioids to prevent addiction and unintentional overdose in patients at risk of abusing them,” the authors write.
ED Physicians Remain Confused about POLST Orders for End-of-Life Care
ERIE, PA – Physician Orders for Life-Sustaining Treatment (POLST) increasingly are how seriously ill patients document their choices related to end-of-life care. The problem, according to a pair of new studies, is that emergency physicians as well as prehospital care providers demonstrate “significant confusion” when confronted with one.
The studies, published recently in the Journal of Patient Safety, find that emergency care providers vary widely in their understanding of the POLST document.
"Our data suggest that POLST orders can be confusing for Pennsylvania emergency physicians, and likely for physicians nationwide," writes Ferdinando L. Mirarchi, DO, of University of Pittsburgh Medical Center (UPMC) Hamot in Erie, PA., and colleagues.
The POLST form is a 1-page, brightly colored document that varies in color and formatting from state to state and serves as an "active medical order" across healthcare settings. Patients use the POLST to designate their choices regarding resuscitation –either do not resuscitate (DNR) or full cardiopulmonary resuscitation (CPR) –and either full or limited treatment as well as “comfort measures" only.
The researchers surveyed Pennsylvania ED physicians and prehospital care providers, including paramedics and emergency medical technicians, to determine their understanding and interpretation of POLST forms. Survey subjects were presented with various clinical scenarios of critically ill patients as well as with POLST forms specifying different options for resuscitation and treatment.
Surveys were completed by 223 emergency physicians and 1,069 prehospital care providers, and rates of "consensus" –defined as 95% agreement –were assessed in the different situations.
Results indicate that in most of the clinical scenarios, for both emergency physicians and prehospital providers, results significantly fell short of consensus benchmarks.
“For scenarios specifying DNR and either full or limited treatment, most chose DNR (59%–84%) and 25% to 75% chose resuscitation,” according to the results. “When the POLST specified DNR with comfort measures, 90% selected DNR and withheld resuscitation. When cardiopulmonary resuscitation/full treatment was presented, 95% selected ‘full code’ and resuscitation.”
Even in the circumstances where the POLST specified "DNR" with "comfort measures" only 10% of emergency physicians and 15% of prehospital providers indicated they would still perform CPR. Only when the POLST form specified “CPR” and “full treatment” did the situation indicate 95% agreement.
"The POLST provides medical orders that are immediately actionable and to be universally honored across various healthcare settings," note the authors, who add that the template, which generally is used by seriously ill patients facing the threat of sudden death in the year, has quickly disseminated across the United States and has now been adopted by more than 20 states with other in the process of considering it.
New Protocol Helps Determine Discharge for Chest Pain Patients
WINSTON-SALEM, NC – One of the challenges when patients present to the emergency department with acute chest pain is determining which patients can be sent home safely and which need to be kept for more intensive care.
A risk-evaluation protocol, recently developed by the Wake Forest Baptist Medical Center, helps ED clinicians make that determination more efficiently, according to a report published recently in the journal Circulation: Cardiovascular Quality and Outcomes.
The study findsthat chest-pain patients evaluated with the new protocol, called the HEART Pathway, had 12% fewer cardiac tests, 21% more early discharges, and shorter hospital stays than those who received standard care. Yet, none of the patients identified for early discharge in either group had a major heart problem within 30 days of their ED visit.
Background information in the articles notes that as many as 10 million chest pain patients present for emergency care in the United States each year. More than half of those patients end up being hospitalized to undergo comprehensive cardiac tests at a national cost of between $10 billion and $13 billion annually.
Fewer than 10% of the patients are found to have acute coronary syndrome (ACS), however.
"The results of this trial demonstrate that, compared to usual care, the HEART Pathway can substantively decrease healthcare utilization among patients with symptoms related to ACS without compromising patient safety," said lead author Simon A. Mahler, MD, associate professor of emergency medicine at Wake Forest Baptist.
The HEART Pathway is based on the widely used HEART score system, which weighs five components –the patient's history, electrocardiogram reading, age, risk factors and levels of troponin, a protein in blood released when the heart muscle is damaged –to determine an individual's risk of having a serious cardiac problem. The Pathway also includes an additional element –a second blood test to measure troponin levels, administered three hours after the first one.
"The HEART Pathway is a decision aid, not a substitute for clinical judgment," Mahler said, "but there is strong evidence to support that its use can both improve evaluation and reduce unnecessary testing, hospitalization and expense."
Older Blood As Good As Fresh for Critically Ill Patients
OTTAWA, CANADA – Milk and blood may both be the elixir of life in certain circumstances, but blood has a much longer shelf life.
In fact, despite conventional wisdom, new research published online recently by the New England of Medicine indicates that blood stored for three weeks is just as good as fresh blood. In other words, if any physicians in your ED are sticklers for fresh blood, show them this study.
The Age of Blood Evaluation (ABLE) study, led by researchers from the Ottawa Hospital Research Institute, is a randomized double-blind trial designed to compare mortality after 90 days in intensive care patients transfused with either fresh blood (stored for an average of six days) or older blood (stored for an average of 22 days). The study included participation from 2,430 adults in 64 medical centers in Canada and Europe – 1,211 patients in the fresh blood group and 1,219 in the older blood group.
"Current blood bank practice is to provide patients with the oldest blood available. Some doctors, however, feel that fresh blood is better,” said co-author Paul Hébert, MD, an intensive care physician-scientist at the Centre de recherche du CHUM and professor at the Université de Montréal.
It turns out that isn’t true at all.
"There was no difference in mortality or organ dysfunction between the two groups, which means that fresh blood is not better than older blood,” points out co-author Dean Fergusson, PhD, a senior scientist at the Ottawa Hospital Research Institute and the University of Ottawa.
The study found that 423 patients receiving fresh blood died within 90 days post-transfusion compared to 398 patients in the older blood group.No significant differences were found among any of the secondary outcomes such as major illness; duration of respiratory, hemodynamic or renal support; hospital length of stay, or transfusions reactions.
The authors note that previous observational and laboratory studies have questioned whether fresh blood might be preferable because of the breakdown of red blood cells and accumulation of toxins during storage but said this study did not bear that out.
Under current standards, blood is stored up to 42 days. Some physicians have begun to ask for fresh blood in recent years, which creates difficulty because of limited supply and because blood collection agencies and hospitals tend to distribute blood on a “first-in, first out” basis to avoid waste, the researchers note.
Yet, the authors conclude, “transfusion of fresh red cells, as compared with standard-issue cells, did not decrease the 90-day mortality among critically ill adults.”
The same study team is planning a similar clinical trial in pediatric patients.
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