ED Push - October 2015 First Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Technology Helps CA EDs Improve Timely Clot-Buster Administration
OAKLAND, CA – New technology that provided both care-decision support for emergency physicians and enabled electronic order entry substantially improved timely administration of clot-busters for acute ischemic stroke, according to a recent study.
The report, which appeared in Annals of Emergency Medicine, summarized what happened when computerized physician order entry was integrated into electronic health records across 16 Kaiser Permanente Northern California medical centers from 2007 to 2012.
Kaiser researchers noted that, after implementation, emergency department stroke guidelines were made available to physicians using order sets. Those provided standardized laboratory, radiographic and drug ordering, as well as information to help clinicians decide the best course of treatment.
"This study demonstrates that computerized physician order entry generally -- and an order set embedded with decision support specifically – can facilitate the delivery of time-sensitive interventions for stroke while minimizing errors," said lead author Dustin Ballard, MD, an emergency medicine physician at the Kaiser Permanente San Rafael Medical Center and an adjunct researcher at the Kaiser Permanente Division of Research. "In this case, the investigation showed that these tools can safely lead to more frequent administration of medication to thin blood and break up blood clots in the brain, a treatment that has been associated with better neurological recovery after stroke."
Study authors point out that improved outcomes and fewer complications usually occur with a systematic approach to the acute management of patients with ischemic stroke, including timely administration of intravenous tissue plasminogen activator (IV tPA) for eligible patients.
"While the technology is not likely to be solely responsible for the improved outcomes observed in this study, it may represent a proxy measure for optimum care for certain patients, in particular those for whom the speed of initiating therapy, the completeness of information available to the clinician, and the intensity of inpatient care make a real difference in short-term outcomes," said co-author David Vinson, MD, an emergency medicine physician at the Kaiser Permanente Roseville Medical Center.
The study team reviewed the cases of 10,081 patients, including 6,686 (66.3%) who were treated in medical centers after computerized physician order entry had been implemented. While 8.9% of those patients received IV tPA in the ED, only 3.3% of patients in EDs without the new technology were given clot-busters.
When the stroke order set was used in combination with the computerized physician order entry, according to the results, IV tPA administration further increased to 12.7%.
"Ultimately, we see the order set itself as optimizing the confluence of two separate processes – a robust computerized physician order entry that integrates care across many providers and locations while limiting errors of omission, combined with a quality initiative that has identified disease-specific best practices and guidelines," study authors write. "We believe that our findings represent a dawning era of electronic health records, one that blends decision support and best practices."
Black Children with Appendicitis Less Likely to Get ED Opioids for Severe Pain
WASHINGTON, DC – No one likes to think they harbor subtle racial bias, least of all emergency department clinicians. Yet, a new study finds that, at EDs in the United States, black children with appendicitis were less likely to be given opioids for severe pain than white children with the same condition. The report also suggests some variations in treatment of more moderate discomfort.
The study on racial disparities in the pain management of children in EDs was published online by JAMA Pediatrics. Background information in the article notes that racial and ethnic differences in ED management of pain have been previously described in terms of lower rates of opioid prescriptions for black and Hispanic patients, but this is one of the few that has looked at possible bias with children.
The study team, led by researchers at the Children's National Health System in Washington, opted to examine the use of analgesics among children diagnosed with appendicitis because guidelines generally recommend pain management in that situation.
Using data from the National Hospital Ambulatory Medical Care Survey from 2003 to 2010 to analyze both the administration of opioid and non-opioid analgesia, the researchers found that, of about 1 million children evaluated in EDs who were diagnosed with appendicitis, 56.8% of patients received any analgesia and 41.3% received any opioid pain medication.
The study team then analyzed the data, adjusting for pain score and ethnicity, finding that black patients with moderate pain were less likely to receive any analgesia than white patients. For severe pain, black patients were less likely to receive opioids than white patients.
No significant difference in overall analgesia administration by race was detected when multiple variables were introduced, but the researchers still found a variance in opioid administration by race: While 12.2% of black children with appendicitis received opioid analgesia, the rate for white children was 33.9%.
Study authors pointed out that the research was limited because they did not know which patients might have declined analgesia and there was no information on analgesia received before arrival at the ED.
"Our findings suggest that there are racial disparities in opioid administration to children with appendicitis, even after adjustment for potential confounders,” the study authors conclude. “More research is needed to understand why such disparities exist. This could help inform the design of interventions to address and eliminate these disparities and to improve pain management for all youths.”
In a related commentary, Eric W. Fleegler, MD, MPH, and Neil L. Schechter, MD, of Boston Children's Hospital and Harvard Medical School, Boston, questioned how the persistence of disparities in treatment could be explained.
“If there is no physiological explanation for differing treatment of the same phenomena, we are left with the notion that subtle biases, implicit and explicit, conscious and unconscious, influence the clinician's judgment,” Fleeger and Schechter write. “It is clear that despite broad recognition that controlling pain is a cornerstone of compassionate care, significant disparities remain in our approach to pain management among different populations. Strategies and available knowledge exist to remedy this unfortunate situation; we can and should do better."
ED Crowding Detrimentally Affects Hand Hygiene Among Staff
TORONTO – When the emergency department is packed with patients, clinicians barely have time to breath. So, it should come as no surprise that handwashing rates also are affected.
What might be shocking, however, is how low the hand hygiene rate can drop among physicians when ED crowding occurs.
A study published online recently by the journal Academic Emergency Medicine sought to determine how much ED crowding affected the rates of hand hygiene among healthcare workers.
To do so, a trained observer measured hand hygiene compliance for 22 months in the 40-bed ED of a 475-bed academic hospital in Toronto. The study team, led by researchers from St. Michael’s Hospital, also compiled ED crowding measurements, including mean daily patient volumes, time to initial physician assessment, and daily nursing hours. Hand hygiene data, measured during 20-minute observation sessions, then were linked to aggregate daily results for each crowding metric.
Overall, hand hygiene compliance was found to be 29% –325 of 1,116 opportunities – with alcohol-based hand rinse used 66% of the time. Nurses accounted for 68% of hand hygiene opportunities and physicians for 18%, with other staff having even lower rates.
Results indicate that the most common indications for hand hygiene were hand hygiene prior to (35%) and hand hygiene following (52%) contact with the patient or his or her environment. Compliance was lower when time to physician assessment was more than 90 minutes. Daily patient volumes and nursing hours were not associated with hand hygiene compliance.
“Strategies that minimize ED crowding may improve ED hand hygiene compliance,” the authors suggest.
Another study, published recently in BMJ Quality & Safety, finds that the time bind in a crowded ED is not the only constraint. In an observational study, Columbia University researchers found other environmental factors at play, such as having patients overflowing into hallways.
From October 2013 to January 2014, trained observers recorded hand hygiene compliance among staff in a single ED according to the World Health Organization ‘My 5 Moments for Hand Hygiene’.
With 1,673 hand hygiene opportunities observed, hand hygiene compliance was significantly lower when the ED was at its highest level of crowding than when the ED was not crowded. It also was lower among hallway care areas than semiprivate care areas.
“Unique environmental conditions pose barriers to hand hygiene compliance in the ED setting and should be considered by ED hand hygiene improvement efforts,” the authors conclude. “Further study is needed to evaluate the impact of these environmental conditions on actual rates of infection transmission.”
Tykes on Trikes Often End Up in ED with Injuries
AUGUSTA, GA – Pedaling a tricycle may not seem to be a daredevil act for a toddler, but it also isn’t completely harmless, as emergency physicians can attest.
In fact, a study published recently in the journal Pediatrics, points out that, in 2012, tricycle accidents were the leading cause of reported toy-related deaths in children.
Noting that little research has been conducted regarding tricycle-related injuries and how to counsel parents appropriately, a study led by researchers from the Medical College of Georgia used nationally representative data to investigate various characteristics of tricycle-related injuries in children presenting to emergency departments.
Pulling from the National Electronic Injury Surveillance System for calendar years 2012 and 2013, the study team collected data regarding tricycle injuries in children younger than 18 years of age, including body regions injured, ED disposition, and demographics.
Results indicate that an estimated 9,340 tricycle-related injuries were treated in US EDs from 2012 to 2013. With an average age at injury of 3, children 2 years old had the highest frequency of injuries, and children 1 to 2 years of age represented 51.9% of all injuries. Most, 63.6% of injuries, occurred in boys.
While lacerations were the most common type of injury overall, internal organ damage occurred most often in 3- and 5-year-olds. Contusions were the most common type of injury in both 1- and 7-year-olds.
The most commonly injured region of the body was the head, which also was most likely to suffer internal damage. As for fractures, those occurred most commonly in elbows, with upper extremities generally more often broken, compared to lower extremities.
About 2.4% of the children were admitted to the hospital after ED treatment.
Seeking to decrease ED visits for tricycles accidents, the study authors call for more use of elbow pads, helmets and greater supervision of children riding the toys. They also recommend some design changes to help make tricycles safer, such as limiting the turning radius or maximum speed, since most of the bikes don’t have brakes.
ED staff might consider reminding parents and caregivers of tricycle-injured children that, to avoid head injuries, the CDC recommends helmets for kids who ride tricycles as long as their neck muscles are developed enough to support them.
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