ED Push - December 2015 Second Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Negligible Effect of Medical Students on ED Length of Stay
PHILADELPHIA – How much do medical students slow down the process in busy emergency departments?
Not much, according to a research letter published in a special medical education issue of JAMA.
Background information in the report, based on research from the Perelman School of Medicine at the University of Pennsylvania, notes that medical students typically perform an initial evaluation of stable patients in EDs prior to supervising residents or attending physicians.
That adds fewer than five minutes to the average length of stay for ED patients, according to the study.
No other significant differences were identified among visit covariates, including ICD-9 code prevalence, between clerkship and control weeks. Weekly resident turnover rate, while significantly lower during the clerkship weeks compared with the control weeks, was not correlated with LOS.
"There has been concern that medical students may appreciably increase patient length of stay in the emergency department," said senior author Kevin R. Scott, MD. "But our findings show only a minimal increase, one that is probably imperceptible to most patients and likely clinically insignificant. What this demonstrates is that medical students are afforded excellent educational opportunities in the emergency department, and can balance this with the desire of both patients and physicians to reduce length of stay."
For the study, the research team compared patient length of stay during a required emergency room rotation for medical students compared to a time period when medical students were not in the ED. Evaluating more than 1.3 million patient cases over a 15-year period at three hospitals, the study team found the total average length of stay was 264.7 minutes, while length of stay was 4.6 minutes longer when students were involved in assessing patients.
"As students, we gradually transition from observing to aiding medical care, but sometimes worry that the additional time we spend with patients may slow care," explained lead author Kimon L.H. Ioannides, a fourth year medical school student at Penn. "This study provides some reassurance that our teachers are able to minimize delays in care for our patients during this transition.”
Novel Aromatherapy: Using Isopropyl Alcohol to Relieve Nausea in ED
SAN ANTONIO –Nausea and vomiting are common conditions in emergency departments, and failure to control them is not only unpleasant for patients and everyone around them but also can led to adverse effects such as dehydration, metabolic alkalosis, gastroesophageal tears and aspiration.
That’s why a recent article in Annals of Emergency Medicine has been so embraced by emergency physicians looking for a safe and inexpensive remedy. It reports that patients suffering from nausea in the ED got significant relief by sniffing pads saturated with isopropyl alcohol compared to a control group sniffing pads saturated with a saline solution.
"We love it when we find a cheap, easy and fast way to bring relief to our patients," said lead author Kenneth Beadle, EMPA-C, of the San Antonio Uniformed Services Health Education Consortium in San Antonio. "Nausea and vomiting are the chief complaint for nearly 5 million emergency patients every year, so this remedy has the potential to help a lot of people."
For the randomized, double-blind, placebo-controlled trial conducted in an urban tertiary care ED, patient nausea and pain were measured with previously published 11-point verbal numeric response scale scores, while patient satisfaction was measured by a five-point Likert scale. The primary outcome was reduction in nausea 10 minutes from initiation of the treatment, with secondary outcomes including patient satisfaction and pain reduction.
Of the 80 patients completing the study, 37 (46.3%) received nasally inhaled isopropyl alcohol and 43 (53.8%) received nasally inhaled normal saline solution. Patients were instructed to inhale deeply through their noses from the pads every two minutes for four minutes, for a maximum of three inhalations. At 10 minutes post-intervention, median nausea verbal numeric response scale score was 3 in the isopropyl alcohol arm vs. 6 in the placebo arm, for an effect size of 3.
At the same time, the median satisfaction score was 4 among patients sniffing isopropyl alcohol, compared to the control group. The two arms didn’t differ significantly in median pain verbal numeric response scale scores or of subsequently receiving rescue anti-emetics.
"Alcohol wipes are safe and there were no adverse effects," Beadle added. "Further research is warranted to test the duration of the effect and performance in comparison to traditional, pharmaceutical anti-emetics. That said, the available evidence suggests these alcohol wipes may be a potent tool for relieving nausea and improving satisfaction among our emergency patients."
Busiest EDs Lag Behind in Instituting Crowding Solutions
WASHINGTON, DC – Here’s some news that likely will come as little surprise to emergency physicians: The most crowded emergency departments in the United States have lagged behind in adopting proven interventions to address backup.
That’s according to a study, published recently in Health Affairs, which evaluated crowding in U.S. hospitals from 2007-10. It found that while the situation has improved somewhat, effective interventions have yet to be adopted by many of the nation's most crowded EDs.
"Emergency department crowding is clearly linked to worse patient care and worse outcomes, including higher mortality rates, higher rates of complications, and errors," said co-author Jesse M. Pines, MD, MBA, of the George Washington University (GW) School of Medicine and Health Sciences. "Patients also, no surprise, have a poorer patient experience. People want fast and effective care, and many of our nation's most crowded emergency departments have not addressed this problem despite the wide availability of proven interventions."
According to the study, the average number of interventions adopted increased from 5.2% to 6.6% over four years. In general, results indicate, more crowded EDs adopted greater numbers of interventions than less crowded EDs. Yet, 19% of the most crowded EDs did not use bedside registration, and 94% did not use surgical schedule smoothing, which helps plan surgical schedules to match inpatient bed availability.
"This data implies that emergency department crowding is still a low priority in many hospitals, despite the fact that it has continued to worsen over the last two decades," added lead author Leah S. Honigman Warner, MD, MPH. "With implementation of the Affordable Care Act and pressure to reduce health care costs, crowding will likely continue to worsen. We know there are effective interventions that can mitigate crowding, now is the time to develop best practices to reduce emergency department crowding so that we can provide the highest-quality patient care."
Emergency Physicians Prescribe Few Opioids Compared to Some Specialties
STANFORD, CA – Emergency physicians sometimes are accused of being among the worst offenders for over-prescribing painkillers and contributing to the opioid overdose epidemic.
A new study suggests that really isn’t true.
The research letter in JAMA Internal Medicine notes that, while prescriptions for opioid pain relievers often were concentrated in specialties for pain, anesthesia, and physical medicine and rehabilitation, general practitioners dominated total prescriptions among Medicare prescribers based on volume.
The study team, led by Stanford University researchers, used prescription drug coverage claims in the 2013 Medicare Part D claims data set to examine data from individual prescribers, including physicians, nurse practitioners, physician assistants and dentists.
With the data representing more than 1.1 billion claims costing nearly $81 billion, researchers zeroed in on opioid prescriptions containing hydrocodone, oxycodone, fentanyl, morphine, methadone, hydromorphone, oxymorphone, meperidine, codeine, opium or levorphanol.
Claims by provider type were 1124.5 for interventional pain management and 921.1 for pain management on a logarithmic scale. On that scale, family practice was at 161.1, representing 15,312,092 claims, and internal medicine at 122 with 12,785,839 claims. Emergency medicine was at a relatively low 51, with 1,767,183 total claims that year.
"The bulk of opioid prescriptions are distributed by the large population of general practitioners," said lead author Jonathan Chen, MD, PhD.
When they looked at prescriber types, opioid prescriptions were most concentrated in interventional pain management, pain management, anesthesiology and physical medicine and rehabilitation specialties.
“Contrary to the California Worker’s Compensation data showing a small subset of prescribers accounting for a disproportionately large percentage of opioid prescribing, Medicare opioid prescribing is distributed across many prescribers and is, if anything, less skewed than all drug prescribing,” according to the study. “The trends hold up across state lines, with negligible geographic variability.”
Researchers note a skewing for total drug costs of Medicare opioid claims, however, with 78% accounted for by 10% of prescribers, noting, “This could be selection of more expensive formulations or higher doses prescribed.”
“High-volume prescribers are not alone responsible for the high national volume of opioid prescriptions, the authors conclude. “Efforts to curtail national opioid overprescribing must address a broad swath of prescribers to be effective.”
“Being a physician myself, I am acutely aware of the emotional angst that can occur when deciding whether to prescribe opioids to a patient who may have simultaneously developed a chronic-pain and substance-dependence problem,” Chen said in a Stanford University press release. “The public health epidemic of opioid overuse is perhaps not surprising given the tenfold increase in volume over the past 20 years."
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