ED Push - January 2015 Second Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
No Benefit Found for Extended Rest in Pediatric Concussion Patients
MILWAUKEE – In hopes of improving concussion recoveries and outcomes, some emergency physicians recommend that pediatric patients presenting with head injuries have strict rest for five days after discharge.
A new study, published recently in Pediatrics, sought to determine if that practice was beneficial compared to the usual care recommendations of one to two days rest followed by gradual return to activity.
The research is important, according to the article, because pediatric head trauma represents a signi?cant injury burden for children, with ED visits for sports-related traumatic brain injury (TBI) increasing 60% over the last 10 years. Most of the patients are discharged from the ED with instructions to rest, although the duration of rest can differ.
“Rest recommendations are motivated by a concern for re-injury during recovery from a concussion,” according to the study by Children’s Hospital of Wisconsin researchers. The authors point out that some retrospective studies and animal models have found early physical and mental activity can impair recovery.
With limited human data on post-injury exertion, expert consensus recommends 24 to 48 hours of rest before beginning a stepwise return, the article notes.
Out of an abundance of caution, however, some clinicians recommend a longer period of rest, with a few even advocating “cocoon therapy,” which restricts patients to several days in a darkened room.
To determine if 5-day rest is superior in avoiding adverse outcomes to usual care, the study team recruited 99 patients aged 11 to 22 years who presented to a pediatric ED within 24 hours of concussion.
Participants underwent neurocognitive, balance, and symptom assessment in the ED and were randomized to strict rest for five days vs. usual care. The patients completed a daily diary, recording physical and mental activity level, energy exertion, and post-concussive symptoms. In addition, neurocognitive and balance assessments were performed at 3 and 10 days post-injury.
Results indicated no benefit to the longer rest period, although researchers noted that the “strict” protocol affected symptom reporting by adolescents.
Post-discharge, both groups reported a 20% decrease in energy exertion and physical activity levels although, as expected, the intervention group reported less school and after-school attendance for days 2 to 5 post-concussion -- 3.8 vs 6.7 hours total.
“There was no clinically signi?cant difference in neurocognitive or balance outcomes,” according to the report. The intervention group reported more daily post-concussive symptoms, however, with a total symptom score over 10 days of 187.9 vs. 131.9 for the control group. They also had slower symptom resolution.
“Recommending strict rest post-injury did not improve outcome and may have contributed to increased symptom reporting,” the authors write. “Usual care (rest for 1–2 days with stepwise return to activity) is currently the best discharge strategy for pediatric mild traumatic brain injury/concussion.”
ED Patient Satisfaction Scores Unaffected by Opioid Prescribing
WORCESTER, MA – Just in case you were worried, refusing to prescribe opioids to patients won’t hurt your emergency department’s patient satisfaction scores.
That’s according to a new study published recently in the Annals of Emergency Medicine, which found no correlation between opioids administered in the ED setting and patient satisfaction scores, researchers report. Wait times and physician and nurse communication were far more significant in affecting the Press Ganey ED patient satisfaction scores, according to the study from University of Massachusetts Medical School researchers.
"Right now there is an epidemic of opioid-related deaths and the FDA has identified prescribers as essential to the reduction of opioid misuse," said study author Kavita Babu, MD, associate professor of emergency medicine and director of the medical toxicology fellowship at UMass. "When we identify modifiable factors, things that we can change, in order to curb this epidemic, one of the issues that comes up frequently is responsible opioid prescribing."
The study notes that ED physicians often are called on to treat painful conditions but the lack of familiarly with the patient, time constraints, and patient safety concerns can make it difficult to know what to do. Those decisions are further complicated when compensation and metrics of care are linked to Press Ganey ED patient satisfaction scores, which may be perceived to be adversely influenced by the failure to administer opioids, the authors point out.
"In conferences and settings where we teach physicians about responsible opioid prescribing, one of the obstacles frequently mentioned is patient satisfaction and the idea that physicians might be chastised or receive less compensation because their patient satisfaction scores are low," Babu said.
To find out if that’s true, the researchers matched patient satisfaction responses to the corresponding de-identified electronic medical record data of 4,749 patients seen in two New England hospital EDs. Patient survey responses were reviewed in the retrospective analysis, as were medication orders, age, sex, race, health insurance status, time of arrival at ED, wait time to see a physician, total length of stay, patient-reported pain levels, and year and month of visit.
Of the 4,749 patients who returned surveys, 48.5% received analgesic medications, and 29.6% received opioid analgesics during their ED visit. In the multivariable analysis, however, receiving analgesic medications or opioid analgesics was not associated with overall patient satisfaction scores, and receipt of greater morphine equivalents was inconsistently associated with lower overall scores.
"Based on these findings the administration of opioids in the emergency department setting does not make patients more satisfied," said Babu. "This suggests that emergency physicians should act in the best interest of the patient when deciding whether to prescribe or administer opioids."
EMTALA Compliance 2015:Addressing CMS Deficiencies, Problematic Standards and Practitioner Liability
Unlimited Staff Education and Training Event – CNE and Recordings Included | Dates: Feb 3 & 10, 2015
Over 1,725 hospitals received deficiencies for failure to comply with the federal EMTALA law. Why? Most hospitals were unprepared. In this 2-part program we cover common deficiencies and the newest regulations so you won’t be caught unaware. Failure to comply and follow EMTALA for all hospitals, including critical access hospitals, could result in loss of Medicare and Medicaid payments. Click here to learn more and register. Learn even more by attending EMTALA & the On-Call Physician, live on March 3, 2015.
EDs Now Have Access to Molecular Testing for Influenza
WALTHAM, MA – Emergency departments now can employ a nucleic acid-based influenza test that promises to provide highly accurate results in as little as 15 minutes.
The FDA recently granted a Clinical Laboratory Improvement Amendments (CLIA) waiver to allow the Alere i Influenza A & B test to be used in a greater variety of healthcare settings, including EDs. The test was previously only available for use in certain laboratories.
“Today’s decision allows the first nucleic acid-based test to be available in clinical settings that previously could not use this technology,” said Alberto Gutierrez, PhD, director of the Office of In Vitro Diagnostics and Radiological Health in the FDA’s Center for Devices and Radiological Health. “We expect many other simple and accurate tests using nucleic acid-based technology to be developed in the near future. Once cleared by FDA, such tests can allow healthcare professionals to receive test results more quickly to inform further diagnostic and treatment decisions.”
The Alere i Influenza A & B test uses a nasal swab sample from patients presenting with signs and symptoms of flu infection. The simple test, which may be performed in the presence of the patient, analyzes DNA and RNA strains to determine the causes of infections.
The Alere product is one of more than 15 rapid influenza detection tests (RIDTs) on the market and one of several producing results in about 15 minutes. The CDC says other RIDTs use enzyme immunoassay technology, however, and have sensitivities ranging from 50% to 70%, which is lower than the typical accuracy for molecular testing.
The FDA granted the waiver under CLIA for the Alere i Influenza A & B test after the manufacturer submitted data demonstrating the test’s ease of use and low risk of false results when used by untrained operators.
“This is critical if the test is to be allowed for use outside of moderate- and high-complexity laboratories,” according to the FDA, which cautioned that negative results do not rule out influenza virus infection The FDA also said the test is intended to aid in diagnosis along with the evaluation of other risk factors.
Clinical study data was collected from more than 500 patients with signs and symptoms of respiratory viral infection tested for influenza using both the Alere i Influenza A & B test and an FDA-cleared molecular comparator. The Alere i Influenza A & B test demonstrated high accuracy when identifying patients with or without influenza A and influenza B by users untrained in laboratory procedures, according to the agency.
"This milestone greatly expands the availability of molecular testing to a wide range of healthcare settings during this influenza season," explained Avi Pelossof, global president of infectious disease at Alere. "By making lab-accurate, actionable results available at the point of care, Alere i empowers healthcare providers to quickly identify and treat people with influenza – improving patients' clinical outcomes, protecting their communities, and reducing healthcare costs."
Molecular testing involves the extraction and analysis of DNA or RNA strands to detect sequences associated with viral and bacterial causes of infections.
“Unlike polymerase chain reaction (PCR) testing, Alere's proprietary Molecular. In Minutes™ (MIM) isothermal nucleic acid amplification technology (iNAT) does not require lengthy and complex thermo cycling or DNA purification, and can therefore deliver PCR-caliber results more quickly – and in a broad range of settings,” the manufacturer said in a press release..
Alere said it recently filed an application maintaining that a Strep A test is substantially equivalent to a legally marketed device and is planning to initiate clinical trials for a respiratory syncytial virus test during the current respiratory season.
Lack of Primary Care Under the ACA Increases ED Visits
DETROIT – Despite hopes that the Patient Protection and Affordable Care Act would ease the demand on emergency departments by allowing more patients to seek care with primary physicians, it hasn’t worked out that way.
In fact, the opposite may be true, according to a recent study published in the American Journal of Emergency Medicine. EDs are used more frequently than before the ACA because of the lack of primary health providers in many urban and rural areas, according to the researchers.
Instead of just calling for more efforts to increase primary care providers, however, the study suggests that EDs should remake themselves to provide for more healthcare needs.
The study, “Access to care issues and the role of EDs in the wake of the Affordable Care Act,” was led by Alexander Janke, a second-year medical student at the Wayne State University School of Medicine. It reviewed data from the 2013 National Health Interview Survey, focusing on 7,233 respondents who reported at least one ED visit in the preceding 12 months.
Results indicate that the ED users – 27.7% who reported no usual source of care and another 35.1% who said they relied on EDs for care – reported that lack of primary care access was the reason. Others said an ED was their “closest provider.” None of those respondents said the issues sending them to the ED were true emergencies.
The overcrowding of EDs for non-emergency issues will remain a problem, according to the study authors, unless EDs “evolve into outlets that service a wider range of healthcare needs rather than function in their current capacity, which is largely to address acute issues in isolation.”
“We found that insurance status is a far less significant predictor of lack of access-based emergency department utilization than usual source of care,” Janke said. “As healthcare services utilization increases in the era of the Affordable Care Act, the shortcomings of primary care accessibility will become increasingly salient. Many patients will simply present to our nation’s emergency departments. Policymakers should consider providing resources for emergency departments in under-resourced communities to address the full range of healthcare needs for patients lacking a stable usual source of care.”
Newly insured patients who cannot access primary care and use EDs instead may not reap the full benefits of healthcare services provided under the ACA, study authors point out, noting that Americans with an established usual source of care are more likely to follow recommended preventive care measures, and demonstrate better rates of awareness, treatment and control of chronic conditions such as hypertension and elevated cholesterol levels.
Yet, EDs offer accessibility, diagnostic testing, procedures and a full range of provider expertise, according to Janke, who adds, “In the paper we say ‘policymakers should provide emergency departments with resources and incentives to better address the full range of their patients' health care needs, especially as utilization picks up under the Affordable Care Act.’ Emergency departments can coordinate better referral and follow-up, and address health issues not related to patients' acute or emergent conditions, for example, as a checkpoint in long-term hypertension management.”
That cannot be done without substantial financial investment, however.
“Emergency department staff already has plenty to do,” Janke pointed out.
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