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EDs Provide More Chronic Disease Management, Less Trauma Care

SAN FRANCISCO – The drama of trauma generally is occurring less often in emergency departments, as clinicians spend more of their time caring for complex, chronic conditions.

That’s according to a new study published recently in the journal Health Affairs. The review of visits to California EDs from 2005 to 2011, led by University of California San Francisco researchers, finds that the emergency department "visit rate" decreased by 0.7% during the study's timeframe, while the rate of ED visits for non-injury diagnoses rose 13.4%. The highest growth rate among non-injury diagnoses included gastrointestinal system diseases, nervous system disorders, and symptoms of abdominal pain.

"While many people think of the ED as simply a place to go when you have a car accident or some type of major trauma, it is increasingly the case that the emergency department is caring for complex medical patients," said lead author Renee Y. Hsia, MD, professor of emergency medicine at UCSF and director of health policy studies in the UCSF Department of Emergency Medicine.

"At the same time, as our population ages, we are seeing a significant rise in older patients with falls or other trauma," Hsia said. "The emergency department therefore plays a critical role in our health care system's ability to care for the acutely injured as well as complex disease."

The rate of ED visits for injuries rose more slowly than non-injury diagnoses among Medicaid beneficiaries and the privately insured, while the rate decreased among the uninsured, according to the point.

Medicare beneficiaries, however, had a similar percent growth for injury and non-injury diagnoses. Non-injury related diagnoses were more common among younger patients 5-44 years old than the older population 45 and older, who had more injury-related diagnoses.

The research illustrates the complexity of emergency care, Hsia said, and it may help policy makers and emergency care physicians to reshape the structure, staffing and funding of emergency departments.

Another finding in the study was that the rate of growth in mental health conditions as a primary diagnosis was significant among the uninsured, Medicare beneficiaries, and the privately insured.



EDs More Prepared Than Ever for Pediatric PatientsHorrors of the Hospital for ED Push

LOS ANGELES – Emergency departments across the United States are better prepared than ever to care for children, and one reason is that almost half have pediatric emergency care coordinators (PECCs), according to a new study.

The percentage of the nation's emergency departments that have a physician or nurse dedicated to address staff training, equipment availability and policies for the care of children has grown to nearly 50%, three times the number in 2003, according to the report published recently by JAMA Pediatrics.

"Emergency department pediatric readiness has improved greatly since a similar assessment was conducted in 2003," said lead author Marianne Gausche-Hill, MD, FACEP, FAAP, of the Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center. The nation's overall pediatric readiness score increased from nearly 70 out of 100, compared to 55 in 2003.

About 83% of EDs (4,149) underwent the recent assessment, according to Gausche-Hill, compared to 29% in 2003. The assessment found that 91% of them have recommended pediatric equipment readily available, based on a joint policy statement issued in 2009 by the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association.

The study results indicate a median weighted pediatric readiness score (WPRS) of 68.9, an improvement and increase from a previously reported WPRS score of 55 across the nation. The WPRS score varied by pediatric patient volume, with low-volume EDs having a median WPRS of 61.4; medium-volume EDS, 69.3; medium-to-high volume EDs, 74.8; and high-volume EDS, 89.8.

Most of the facilities, 59.3%, have nurse pediatric emergency care coordinators, with 47.5% reporting that a physician performs that function. Both types of coordinators were in place in 42% of the EDs participating.

Lower-volume hospitals reported a higher percentage of family medicine-trained physicians providing pediatric care (78.9%) compared with high-volume hospitals (32.1%), where most physicians caring for children were trained in emergency medicine or pediatric emergency medicine.

The electronic assessment, which was conducted from January to August 2013, still found some areas where improvement is needed, however. Those include:

  • Disaster plans, with only 47% having a plan that addresses issues specific to the care of children.
  • Equipment, with at least 15% of EDs lacking one or more specific pieces of equipment recommended by the 2009 guidelines, such as pediatric Magill forceps for removal of airway foreign bodies.
  • Guidelines implementation, with nearly 8% reporting difficulty meeting them for reasons such as cost of training personnel (54%) and lack of educational resources (49%).


After Stroke, Genders Differ in Reasons for rtPA Treatment Exclusion

PROVIDENCE, RI – Does treatment with the common clot-dissolving drug, recombinant tissue plasminogen activator (rtPA) vary according to gender?

That question was explored by research published recently in the journal Stroke. The study team, led by researchers from Brown University and Rhode Island Hospital, analyzed stroke treatment records to determine that men and women just have different physiological reasons for being excluded from administration of rtPA.

Stroke is the third leading cause of death for women, but the fifth leading cause of death for men. Annually, 55,000 more women have strokes than men.

"Although men and women had similar overall eligibility rates for rtPA, women were more likely to have severe hypertension –a potentially treatable condition but a reason they can be excluded from receiving tPA," said primary author Tracy Madsen, MD, an emergency department physician at Rhode Island Hospital. "Interestingly, although the women were more likely to have severe hypertension, this treatable condition was often untreated.”

Women were also more likely to be excluded from rtPA treatment because of advanced age and because they tended to have more major strokes.

For the study, researchers looked at the records of all adult ischemic stroke patients at 16 hospitals in southwest Ohio and northern Kentucky in 2005. Patient eligibility for rtPA treatment and individual exclusion criteria was determined using the 2013 AHA and European Cooperative Acute Stroke Study (ECASS) III guidelines.

Of the 1,837 ischemic strokes identified, 58% were in women, with a median age of 72.2 compared to 66.1 for males, and 24% of the patients were black. In general, eligibility for r-tPA was found to be similar by sex –6.8% men and 6.1% women –even after adjusting for age. The percentage of patients arriving beyond the 3-4.5 hour time windows were similar across the genders, but more women had severe hypertension. More women were older than 80 and had National Institutes of Health Stroke Scale scores greater than 25.

“Within a large, biracial population, eligibility for r-tPA was similar by sex,” the authors conclude. “Women were more likely to have the modifiable exclusion criterion of severe hypertension but were not more likely to be treated. Women were more likely to have two of the five ECASS III exclusion criteria.”

They add that “under-treatment of hypertension in women is a potentially modifiable contributor to reported differences in r-tPA administration.”


The No. 1 Reason Why Emergency Physicians Get Sued

NAPA, CA –The person who never meets a stranger is highly unlikely to be an emergency physician.

The very nature of the job requires dealing effectively with patients who are previously unknown and often have numerous co-morbidities, which may or may not be revealed. Failure to diagnose and treat them effectively could mean meeting them again – in court.

A new study by The Doctors Company, the nation's largest physician-owned medical malpractice insurer, indicates that diagnosis-related issues are, by far, the most common causes of lawsuits against emergency physicians.

For the study, researchers looked at 332 emergency medicine claims that closed from 2007-2013. The top reasons for getting sued include:

  • Diagnostic-related issues, such as failure to establish a differential diagnosis or failure to consider available clinical information, indicated in 57% of the claims;
  • Improper management of treatment, such as failure to stabilize a patient’s neck following an accident with trauma to head and neck, resulting in paraplegia, found in 13% of cases;
  • Improper performance of a treatment or procedure, such as intubation of the respiratory tract in 5% of the claims; and
  • Failure to order medication, such as fibrinolytic therapy in acute MI or stroke within the recommended time frames in 3% of the claims.

What factors were most likely to contribute to patient injury? The study offered the following answers:

  • Inadequate patient assessment in 52% of cases, potentially leading to failure in diagnosis;
  • Patient factors, such as obesity in 21% of cases. Delivery of care sometimes was delayed due to lack of adequate equipment for treating or evaluating obese patients;
  • Poor communication among providers, including failure to review the medical record 17% of the time;
  • Communication barriers between the provider and patient/family, such as language barriers, in 14% of cases. That sometimes led to inadequate follow-up instructions;
  • Insufficient documentation 13% of the time, including too little information about clinical findings, and
  • Problems related to workflow and workload in 12% of claims, such as fewer staff or services available on a weekend, at night or over holiday periods.

"This study indicates that the broad base of clinical problems faced by emergency physicians increases risks and highlights the importance of taking steps such as completing a thorough differential diagnosis for each patient," said David B. Troxel, MD, medical director of The Doctors Company. "If an incorrect diagnosis was to occur and documentation shows it was considered and ruled out, that may reduce the physician's liability risk. “

The Doctors Company recommended the following tips to help emergency physicians avoid diagnostic errors:

  • Avoiding first-impression or intuition-based diagnoses.
  • Completing a thorough differential diagnosis for each patient.
  • Using diagnostic prompts to help ensure all diagnoses are considered.
  • Documenting the differential diagnosis.
  • Making sure that all specialists who are called to evaluate emergency department patients receive a comprehensive summary of the clinical picture, including history, physical findings, and diagnostic studies.
  • Assuring during the handoff discussion who has responsibility for review and follow-up of all test results and diagnostic studies.


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