Routine Inpatient Admission Usually Unnecessary for Chest Pain
COLUMBUS, OH – Routine inpatient admission may not be the best option for patients presenting with chest pain but who have negative findings and non-concerning vital signs after an emergency department evaluation.
A study recently published in JAMA Internal Medicine suggests that those patients rarely had adverse cardiac events.
Background in the report, led by Ohio State University researchers, notes that patients with potentially ischemic chest pain are commonly admitted to the hospital or observed after a negative evaluation in the ED because of fear of adverse events. Until now, however, no large trials had examined the short-term risk for a clinically relevant adverse cardiac event, including inpatient ST-segment elevation myocardial infarction (STEMI), life-threatening arrhythmia, cardiac or respiratory arrest, or death, according to the study.
"We wanted to determine the risk to help assess whether this population of patients could safely go home and do further outpatient testing within a day or two," said Michael Weinstock, MD, a professor of emergency medicine at The Ohio State University College of Medicine and chairman of the Emergency Department at Mount Carmel St. Ann's Hospital.
For the study, researchers reviewed data collected from EDs at three community teaching hospitals on adults who were admitted to the hospital or observed after presenting with chest pain, chest tightness, chest burning or chest pressure and with negative findings for serial biomarkers. The primary outcome measurement was a composite of life-threatening arrhythmia, inpatient STEMI, cardiac or respiratory arrest, or death.
Of the 45,416 encounters examined by the authors, 11,230 patients – average age 58 and 55% female – met the criteria to be included in the study. One or more of the primary outcomes occurred in 20 of the 11,230 patients, for a rate of 0.18%.
The authors point out that, after excluding from the 20 patients those patients who were not likely to be sent home from the ED because of abnormal vital signs or other concerning findings, a primary outcome event occurred in only four patients, 0.06% of the total.
"Our study does not demonstrate that patients derive no utility from further management or diagnostic workup after the ED evaluation,” the authors write. “We believe that judicious follow-up is in the best interest of most such patients. However, our findings suggest that further evaluation may be best performed in the outpatient rather than the inpatient setting, and that this information should be integrated into shared decision-making discussions regarding potential admission.”
The researchers also called for a reconsideration of “current recommendations to admit, observe or perform provocative testing routinely on patients after an ED evaluation for chest pain has negative findings.”
"We'd like to see more emergency medicine physicians having that bedside conversation to ensure the chest pain patient knows the risks and benefits of hospitalization compared to outpatient evaluation,” Weinstock emphasized. “We think continuing evaluation in an outpatient setting is not only safer for the patient, it's a less costly approach for the healthcare system."
EDMONTON, ALBERTA – Patients who regularly show up at emergency departments might be labeled “frequent flyers” and their complaints might be viewed with some suspicion, but a new Canadian study offers evidence that they should be taken very seriously.
The study, published online in Emergency Medicine Journal, suggests those patients are more than twice as likely as infrequent users to die, be admitted to hospital, or require other outpatient treatment. The analysis of available evidence was conducted by researchers from the University of Alberta in Edmonton.
The report also notes that frequent users make up a substantial percentage of ED patients accounting for up to one in 12 patients seeking emergency care and around one in four of all visits.
The article was based on a search of seven electronic databases of research relating to the frequency and outcomes of ED use by adults. Out of a total of more than 4,000 potential studies, 31 relevant pieces of research published between 1990 and 2013 were included in the final analysis.
The studies defined frequent users as patients who visited EDs from four or more times up to 20 times a year. Based on seven studies looking at death rates, the analysis indicated that patients in those categories were more than twice as likely to die as those who rarely sought emergency care.
In addition, frequent users were around 2.5 times as likely to be admitted or to require at least one outpatient clinic visit as infrequent users.
"Our results suggest that, despite heterogeneity, frequent users are a distinct and high risk group," the authors write, suggesting a more targeted proactive approach to managing the cases.
One difficulty, they explain, is a lack of any consensus as to what constitutes a frequent user. That makes it difficult to compare patients and come up with recommendations.
“Frequent ED users appear to experience higher mortality, hospital admissions and outpatient visits compared with non-frequent users, and may benefit from targeted interventions,” the study concludes. “Standardized definitions to facilitate comparable research are urgently needed.”
ED Palliative Care Screening Can Reduce Admissions for Older Patients
NEW YORK – Emergency departments can play a critical role in reducing the number of geriatric patients admitted to intensive care units, which could both extend lives and reduce Medicare costs, according to a three-year analysis.
The report, published recently in the journal Health Affairs, notes that those goals can be achieved by applying palliative care principles to EDs.
"Data show that more than half of Americans ages 65 and older are seen in the emergency department in the last month of their lives, and that the number and rate of admissions to intensive care units among older adults who are seen in the ED have also increased," said lead author Corita Grudzen, MD, a former Mount Sinai Health System physician. "Our findings suggest that early palliative care inpatient consultation can improve care for older patients, decrease hospital lengths-of-stay and costs, and even extend life.”
The new model for ED care was developed as Mount Sinai's Geriatric Emergency Department Innovations in Care Through Workforce, Informatics and Structural Enhancements program (GEDI WISE).
As part of the training at Mount Sinai, ED triage nurses and nurse practitioners learned to screen patients aged 65 and older to identify those at high risk of ED revisit and hospital readmission as well as those suitable for and desiring palliative and hospice care. They also learned how to expedite referrals.
After screening with the Identification of Seniors at Risk tool, instituted in October 2012, 59% of the 8,519 visitors 65 and older to Mount Sinai's ED had a score that indicated an increased risk for revisit and readmission. The study points out that the five most common presenting diagnoses among those patients were chest pain, shortness of breath, malaise and fatigue, abdominal pain, and dizziness.
Between January 2011 and May 2013, the percentage of geriatric ED admissions to the intensive care unit fell significantly, from 2.3% to 0.9%. The 1.4% drop represents 535 averted admissions among 38,240 unique ED encounters, saving Medicare $3.14 million.
"This study shows that identifying emergency patients who would benefit from palliative care interventions may both improve the quality of care and reduce costs," said Lynne D. Richardson, MD, who developed the model. "This could result in a better match of older adults' goals of care with the environments to which they are discharged from the ED, including decreased admissions to the ICU, and increased referrals to hospice and palliative care provided at home."
Study authors caution that the decline in admissions cannot be solely attributed to the GEDI WISE program because other geriatric care innovations were implemented during the study period.
STEMI Visits to EDs Decline, But Transfers Increase
NASHVILLE – It might be hard to believe as you look out on a packed waiting room, but emergency department visits actually are declining for one common presentation – ST-elevation myocardial infarction (STEMI), the most serious form of heart attack.
At the same time, rates of transfer to another ED increased for those patients, especially if they didn’t have health insurance.
The study on declines in STEMI visits, touted by researchers as the first of its kind, was presented at the annual meeting of the Society for Academic Emergency Medicine in San Diego.
The investigative team, led by Vanderbilt University researchers, conducted a descriptive epidemiological analysis of STEMI visits to EDs between 2006 through 2011 using the Nationwide Emergency Department Sample data. Included in the investigation were adult ED visits with a diagnosis of STEMI and calculated incidence rates for STEMI ED visits using U.S. census population data.
Results showed a 24% decrease: From 2006-11, there was a mean of 258,106 STEMIs presenting to EDs per year, decreasing from 300,466 in 2006 to 227,343 in 2011.
The study indicated that incidence of ED STEMI visits per 10,000 adults declined from 10.1 in 2006 to 7.3 in 2011, with the Midwest having the highest rate at 10.0 and the West with the lowest at 6.6.
Over the study period, the incidence of STEMI decreased for all age groups and regions.
“The reasons for the decline may include efforts to streamline angioplasty times by ED bypass, as well as greater use of effective treatments for cardiovascular disease," said Michael J. Ward, MD, assistant professor of Emergency Medicine at Vanderbilt. "The study is significant because these estimates play an essential role in hospital resource allocation strategies."
The presentation also pointed out that “efforts to streamline door-to-balloon times by ED bypass, as well as greater use of effective treatments for cardiovascular disease, may decrease ED STEMI presentation.”
In a separate analysis of the same data, which was also presented earlier this year, transfer rates of STEMI patients increased from 15% in 2006 to 20.6% in 2011. The study team found that patients without insurance were 60% more likely to be transferred when presenting to an ED with STEMI than patients with insurance.
Part of the problem, according to the authors, is that only 31% of U.S. hospitals have primary percutaneous coronary intervention (PCI) capabilities for STEMI patients.
Still, they conclude, “Controlling for other variables, having no medical insurance was independently associated with higher transfer rates compared with having private or government insurance. These results suggest that insurance status influences the location of care for patients presenting to the ED with STEMI.”
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