ED Push - November 2015 Second Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Have a Gut Feeling about Abdominal Pain? You Might Think Again
HOUSTON – Stomach and abdominal pain, cramps and spasms are the leading reasons for emergency department visits, making up more than 8% of all presentations, according to the National Hospital Ambulatory Medical Care Survey.
The problem, according to research published recently in the Emergency Medical Journal, is that acute abdominal pain also can have a high rate of misdiagnosis.
Researchers from the Baylor College of Medicine and the Michael E. DeBakey Veterans Affairs Medical Center, both in Houston, report that diagnostic process breakdowns in ED patients with abdominal pain most commonly involved history taking, ordering insufficient tests in the patient–provider encounter and problems with follow-up of abnormal test results.
“In looking at the prior emergency medicine literature, abdominal pain was one of the chief complaints that was most frequently associated with diagnostic errors, but it had the least amount of research done on it,” said Laura Medford-Davis, MD, assistant professor of emergency medicine at Baylor.
Hardeep Singh, MD, of Baylor and the VA added, “Not only is it fairly common as a presenting symptom, but it’s also one that could be missed or misdiagnosed.”
For the study, researchers used electronic health records to develop an electronic trigger to help identify patients who presented with acute abdominal pain, returned within 10 days after their first ER visit and were admitted to the hospital when they returned.
Reviewing the electronic records of the 100 patients returning to the ED, the study group found 35 diagnostic errors during the initial visits. More than two-thirds of the errors were related to the patient/provider encounter, including history taking, the initial examination or failure to order additional tests at the time the patient presented. Follow-up of abnormal test results also was a problem.
The study identifies two errors that could have caused immediate death, one that had the potential for very serious damage and two more that had the potential for very serious harm.
“Emergency rooms are busy and often chaotic. Moreover, the diagnosis is often not clear when patients first present nor is diagnosis always black and white,” Singh explained. “Our methodology of using rigorous reviews overcomes some of the limitations to measure misdiagnosis. Once these measurements are in place, emergency departments can implement improvement strategies for these types of diagnostic errors.”
Researchers call for better follow-up and reporting strategies for the ED and intervention programs to detect and reduce risk of misdiagnosis, while also recommending more patient education on what they should do when their condition changes.
Avoiding Epinephrine Auto-injector Injuries in Children
SEATTLE – Epinephrine auto-injectors can be a double-edged sword for children with severe allergies. They save lives during episodes of anaphylaxis but also sometimes cause severe injuries.
That’s according to a recent study in Annals of Emergency Medicine, which identifies potential injury-causing design features of EpiPens, the most commonly used auto-injector.
"We were surprised by the severity of some of these injuries, including thigh lacerations and embedded needles," said lead study author Julie Brown, MDCM, MPH, of Seattle Children's Hospital and the University of Washington in Seattle. "We can't think of anywhere else in pediatric medicine where we would hold a needle in an awake child's leg for 10 seconds. That's a set-up for injury, particularly in the uncontrolled, stressful setting of anaphylaxis. In addition, the instructions for use do not mention patient restraint, so parents are not appropriately prepared."
For the study, researchers identified 25 cases of epinephrine auto-injector-related injuries after using the device to treat a child’s allergic reaction. (An additional case involved a 5-year-old child who accidentally injected himself in the ankle with his older cousin's EpiPen, requiring removal of the bent needle at the ED.)
Lacerations, some up to 3-inches long, occurred in 20 children and one nurse injured during administration. In four cases, the needle stuck in the child's limb.
In most cases, EpiPens were administered by parents, including some medical professionals. In six cases, injuries occurred during treatment by nurses, with three others caused by educators.
To reduce injuries, Brown and her colleagues recommend immobilizing the child’s leg and keeping the site of delivery as controlled as possible. In addition, the needle, which should be strong enough that it doesn’t bend during use, should remain inserted in the thigh for as short a time as possible. Never reinsert the needle, they advise.
Of the three epinephrine auto-injectors currently available in North America, none include instructions to immobilize the child’s leg, the study points out, and only one has a needle that self-retracts in two seconds. The others have needles that remain in the thigh during the 10 seconds that the user is instructed to hold the device against the leg, yet their instructions do not caution against reinjection if the needle is dislodged during these 10 seconds.
The self-retracting Auvi-Q (Allerject in Canada) device “would appear to be a safer design for use in children," Brown said. “While EpiPen likely holds a larger share of the epinephrine auto-injector market, it is notable that we did not see any injuries associated with the use of Auvi-Q or Allerject devices, even in recent years."
She added, "We want to emphasize that these injuries are uncommon and should not deter parents and patients from using their epinephrine auto-injectors when needed. Epinephrine is a life-saving medication that must be given early in the course of anaphylaxis. Our goal in reporting these injuries is not to create fear of the EpiPen device but simply to identify limitations with the device, and hopefully motivate improvements in product design and instructions for use."
Most ED Physicians, Administrators Unhappy with Technology Systems
BOSTON – A new survey suggests that the majority of emergency department physicians and administrative/nursing managers believe their hospitals rushed to purchase electronic health records and ED-related systems between 2010 and 2013 to avoid losing federal meaningful use dollars, yet the result has been falling productivity, rising liability and stalled connectivity.
The independent survey, conducted by Black Book, involved 738 ED administrative and nursing managers, as well as 1,104 ED physicians. The vast majority, 89%, expressed concerns about how EHRs and ED systems were selected and implemented.
While increasing overcrowding is causing problems for EDs, the survey reports that lack of Emergency Department Information System (EDIS) usability and interoperability to external providers isn’t helping matters. That’s why so many hospitals, 35% of those with more than 150 beds, are currently, or plan to replace their EDIS in 2016, Black Book reports.
The majority of replacements (69%) will be those now using enterprise EHR emergency modules, opting for best-of-breed EDIS systems that can integrate with the hospital's EHR, the survey adds.
Interestingly, ED physician and nursing staff are now being included in the EDIS decision, unlike a few years ago when the threat of losing government dollars forced hospitals to move as quickly as possible.
In 2010, Black Book surveys noted that only 7% of ED physicians and 2% of ED nursing staff were involved on the EDIS selection teams where enterprise EHRs were given as the only technology option for their respective EDs. In 2015, as well as in the 2016 pending EDIS selection processes, 70% of ED physicians and 16% of ED nurses said they feel as if they are playing a role.
While, 39% of hospitals with enterprise EHR emergency modules identify themselves as moderately to highly dissatisfied with their current EDIS, nearly all, 90%, ED managers and physicians complain that they are stuck with making hospital-wide generic EHR systems work, and/or they have been denied budget funds for 2016 EDIS replacements.
"Most best-of-breed EDIS solutions, not all, are fined tuned for the emergency department environment and workflows," said Doug Brown, Managing Partner of Black Book. "In contrast, enterprise EHR solutions have typically been very generic with difficult customization processes and long implementations for emergency departments."
The survey was conducted from August through October of this year.
Brief ED Intervention Reduces Risky Drinking Issues for Young Patients
ANN ARBOR, MI – A short intervention provided in the emergency department to young people can decrease their alcohol consumption and problems related to drinking over the following year, according to a five-year trial...
The trial, funded by the National Institute on Alcoholism and Alcohol Abuse, examined the effectiveness of an ED-based brief intervention, either delivered by a computer or a therapist, on reducing over the next year alcohol consumption and alcohol-related consequences, including psychosocial problems, driving under the influence, alcohol-related injuries and alcohol-related drug use. Results were published online by the journal Pediatrics.
University of Michigan researchers and colleagues note that early interventions are needed to reduce underage drinking and associated injury, yet how to reach young patients with risky drinking issues has been a challenge.
For the study, patients ages 14 to 20, who were medically stable and seeking any type of medical care, were screened on ED arrival for risky drinking. Those who reported risky drinking were then randomly assigned to receive a brief intervention, either by a therapist or standalone interactive computer program, or were assigned to a control group.
Of the 4,389 patients screened, 24% reported risky drinking behaviors. No matter what kind of intervention was provided to them during their ED visits, the study found, those young people had reduced future alcohol consumption and consequences from their drinking.
Results indicate that both the live therapist and computer brief interventions significantly reduced alcohol consumption among the patients at the three-month follow up visit, alcohol-related consequences at three and 12 months, and prescription drug use at 12 months.
In addition, the computer brief intervention reduced the frequency of driving under the influence at 12 months and the therapist brief intervention reduced the frequency of alcohol-related injuries at 12 months.
"The study highlights that a single-session intervention in the emergency department can play a role in decreasing underage drinking among youth," said lead author Rebecca Cunningham, MD. "Emergency department staff is focused on urgent medical care. The finding that the computer program brief intervention helped youth reduce risky drinking is very promising, especially as an approach that is easy for healthcare sites to use without requiring dedicated staff time to administer."
"Our trial suggests just one brief intervention session, no matter the delivery type, has great promise among underage drinkers," added co-author Maureen Walton, MPH, PhD.
UPCOMING [LIVE] WEBINARS
Advancing Patient Safety in the ED: Risks, Challenges and Corrective Initiatives
Live: November 17 Credits: 2 CNE
CMS CAH CoP Update: Drugs, Pharmacy & Nursing
Live: November 19 Credits: 2 CNE
Uncovering Patient Safety and the 'Just Culture' Theory
Live: December 2 Credits: 2 CNE
Diarrhea in the Acute Care Setting
Live: December 3 Credits: 1 CNE & CME
Identifying and Addressing Burnout
Live: December 10 Credits: 1.5 CNE
[ON-DEMAND] WEBINARS
Human Trafficking in Healthcare: Awareness & Combating
Credits: 1 CNE
