ED Push - February 2016 First Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
ED Palliative Care Discussion Improves Quality of Life for Cancer Patients
NEW YORK – In many cases, consultation about the availability of palliative care doesn’t occur until an advanced cancer patient has been hospitalized for a week.
A recent study sought to determine how quality of life and survival would be affected if a palliative care consultation was instead initiated in the emergency department before admission, thereby circumventing intensive end-of-life care.
The report, published recently in JAMA Oncology, found that the ED consultation led to improved quality of life with no statistically significant effect on survival rates.
For the study, a New York University-led study team conducted a randomized clinical trial to compare quality of life, depression, healthcare utilization, and survival in ED patients with advanced cancer randomly assigned to an intervention with an ED-initiated palliative care consultation as opposed to usual care.
Of the 136 participants, 69 patients were in the palliative care consultation intervention and 67 in usual care, where they might also may have received a palliative care consultation if it was requested by the admitting team or an oncologist. Among the 69 patients in the intervention, 41 died by the end of a year, as did 44 of the 67 patients who received usual care.
Results indicate that the ED palliative care intervention was associated with increased quality-of-life scores from study enrollment to week 12 – an average increase of 5.91 points in the intervention vs. an increase of 1.08 in the usual care group.
In addition, median survival was longer for patients in the intervention at 289 days, compared with the usual care group, 132 days, although the difference was not statistically significant because of the extremely variable length of survival in the study group.
No statistically significant differences were found for depression, admission to the intensive care unit, and discharge to hospice. The effect of palliative care on healthcare utilization, meanwhile, was "more nuanced" in the study, according to the authors.
"Emergency department-initiated palliative care consultation improved QOL [quality of life] in patients with advanced cancer and does not seem to shorten survival; the impact on healthcare utilization and depression is less clear and warrants further study," the study concludes.
In a related commentary, Eduardo Bruera, MD, of the University of Texas MD Anderson Cancer Center in Houston, asks, “Where do we go from here?”
Bruera answers, “It is important to define and test criteria for palliative care referral from the ED in daily clinical practices. ... It will also be important to understand the attitudes and adherence of patients when referred to outpatient palliative care from the ED. In view of the findings of this study, this research is much needed and justified.”
‘Clot Busting’ Also Benefits Patients Unable to Live Independently Before Stroke
DALLAS – Intravenous clot busting appears to be safe and effective even for patients who are unable to live completely independently before suffering a stroke.
That’s according to new research published in the American Heart Association's journal Stroke.
The European multicenter study researched the effect of intravenous thrombolysis (IVT) among ischemic stroke patients with preexisting dependency, defined as being unable to live alone without help from another person. Background information in the report notes that patients with prior dependency are often excluded from clinical trials of IVT and, therefore, might not be treated with clot busters due to the expected higher risk of bleeding complications and lower treatment response.
"These findings prove that randomized-controlled IVT trials should be considered for such patients," said lead author Henrik Gensicke, MD, of the University Hospital Basel in Switzerland.
Among 7,430 IVT-treated patients in 12 European stroke centers, 6.6% were dependent prior to stroke. Researchers determined the degree of disability at three months after stroke onset and whether the group reached at least pre-stroke dependence levels.
Prior stroke, dementia, heart, and bone diseases were the most common causes of preexisting dependency, and the dependent patients tended to be older, more often female, had suffered more severe strokes, and were more likely to be prescribed antithrombotic medication than previously independent patients.
While dependent patients were twice as likely to die as independent patients within three months after IVT treatment, poor outcome and intracranial hemorrhages were equally frequent in both groups.
Furthermore, among three-month survivors, the proportion of dependent patients with poor outcome did not differ from independent patients. In fact, after adjusting for age and stroke severity, dependent patients were at lower risk of poor outcomes than independent patients.
"Concerns of higher complication rates from IVT-treatment resulting in a less-than-favorable risk-benefit ratio for dependent patients might be unjustified and perhaps should be set aside to allow further study," Gensicke said in an American Heart Association press release.
“IVT-treated stroke patients who were dependent on the daily help of others before stroke carry a higher mortality risk than previously independent patients,” the study authors concluded. “The risk of symptomatic intracranial hemorrhage and the likelihood of poor outcome were not independently influenced by previous dependency. Among survivors, poor outcome was avoided at least as effectively in previously dependent patients. Thus, withholding IVT in previously dependent patients might not be justified.”
EDs Increase Use of CT Scans to Evaluate Non-Serious Injuries
SAN FRANCISCO – The number of patients with non-serious injuries who undergo CT scans in California emergency departments doubled in an eight-year period, according to a new study which posits reasons why use of imaging has increased.
The study, published in the Journal of Surgical Research, reports that twice as many patients with non-serious injuries, such as fractures or neck strain, underwent CT scans in EDs from 2005 to 2013.
The research team from the University of California, San Francisco and Stanford University cautions, however, that, while CT scans might enable quicker diagnosis of life-threatening conditions, imaging is not without risk: Exposure to its ionizing radiation is associated with an increased risk of cancer. The article cites a 2009 report by the Food and Drug Administration that a single CT scan could be associated with a fatal cancer in one in 2,000 patients.
For the study, the researchers reviewed more than 8 million adult patient visits at 348 state hospitals, using data from the California Office of Statewide Health Planning and Development. Results indicate that 7.17% of patients who were discharged from EDs after presenting with injuries such as minor falls or low-impact vehicle accidents underwent at least one CT scan in 2013, compared to 3.51% in 2005.
"The reasons for this increase are multifactorial," suggested senior author Renee Hsia, MD, professor of emergency medicine and health policy at UCSF. "They range from defensive medicine practices, the superior diagnostic accuracy of CT scans compared with X-rays, to their increased availability and convenience in emergency departments, and the demand to expedite discharge of patients."
CTs tracked in the study were more likely to be ordered in high-level trauma centers, with 39% ordered at level I and II trauma centers, compared with 3% at low-level centers.
"This may reflect an underlying work culture largely centered around the management of severely injured patients, guided by standard trauma CT protocols, and also the fact that level I and II trauma centers see sicker patients," study authors noted.
Patients between the ages of 18 and 24, "those at greatest risk for radiation," as well as those over 45, appeared most likely to be scanned, according to the research.
"With the aging of the U.S. population, physicians may be influenced toward greater advanced imaging even in the case of low-mechanism injuries, given the atypical presentations and more serious pathology that older adults may have," Hsia said in a UCSF press release.
According to the authors, the use of CTs rose from 2005 to 2009, followed by a gradual decline to 2011 – possibly reflecting awareness of overuse -- which was followed by resurgence from 2011 to 2013 that almost reached the high levels of 2009.
"The message for both patients and physicians is that there are long-term risks associated with radiation exposure and there may be situations where imaging is not definitively warranted or beneficial," Hsia said. "We can't conclusively say which cases should not involve imaging, since every patient and every circumstance is different, but given that it is getting easier and easier to get CT scans, we need to be cautious in weighing their risks and benefits."
Older Accident Victims Often Suffer Pain, Physical Decline After ED Discharge
CHAPEL HILL, NC – For many older victims of motor vehicle crashes, the accident itself, treatment, and discharge from the emergency department are just the beginning of their ordeal, according to a new report.
The study, published recently in the Annals of Emergency Medicine, describes the incidence, risk factors, and consequences of persistent pain among older adults evaluated in the ED after a vehicle accident.
A University of North Carolina Chapel Hill-led study team conducted the prospective longitudinal study of patients aged 65 years or older who presented to one of eight EDs after motor vehicle crashes between June 2011 and June 2014 and were discharged home after evaluation.
Investigators used in-person interviews to gather information with follow-up data obtained through mail-in survey or telephone call. Pain severity on a 0-to-10 scale overall and for 15 parts of the body were assessed at each follow-up point. After six months, participants reporting pain severity greater than or equal to 4 attributed to the motor vehicle crash were defined as having persistent pain.
Results indicate that, of the 161 participants, 72% reported moderate to severe pain at the ED evaluation. At 6 months, 26% of participants still reported moderate to severe motor vehicle crash-related pain.
Characteristics associated with persistent pain included acute pain severity; pain located in the head, neck, and jaw or lower back and legs; poor self-rated health; less formal education; pre-motor vehicle crash depressive symptoms; and patient’s expected time to physical recovery of more than 30 days.
Compared with patients without persistent pain, those with persistent pain were substantially more likely at six-month follow-up to have also experienced a decline in their capacity for physical function -- 73% vs. 36%.
They also were more likely to report a new difficulty with activities of daily living, 42% vs.17%; a 1-point or more reduction in overall self-rated health on a 5-point scale, 54% vs. 30%; and a change in their living situation to obtain additional help, 23% versus 8%.
“Among older adults discharged home from the ED post-evaluation after a motor vehicle crash, persistent pain is common and frequently associated with functional decline and disability,” study authors concluded.
UPCOMING [LIVE] WEBINARS
Safe Opioid Use: Meeting the CMS CoP Hospital Requirements
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Violence Prevention in Healthcare: OSHA Requirements
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Restraint and Seclusion: The Most Problematic of All CMS Standards
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CMS Medical Records: What You Need to Know
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Give Falls the Slip: TJC & CMS Hospital CoPs & Standards
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Professionalism in Social Media: Guidelines for Healthcare Workers
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IV Medication & Blood Administration: Did Your Hospital get the Memo?
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Patient Rights: Complying with the CMS Hospital CoPs
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