ED Push - February 2016 Second Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Pregnant Women With Flu Need Antiviral Treatment ASAP
ATLANTA – Pregnant women presenting to the emergency department with severe influenza should be treated as soon as possible with the antiviral drug oseltamivir, even before test results confirm the infection, according to a new study.
An article published online by The Journal of Infectious Diseases notes that expectant mothers are at higher risk for serious illness and complications, including death, from the flu.
Study authors from the national Centers for Disease Control and Prevention recommend that, for expectant mothers hospitalized with flu, speedy initiation of oseltamivir could shorten their time in the hospital, especially in severe cases. Severe influenza was defined by cases involving intensive care unit admission, mechanical ventilation, respiratory failure, pulmonary embolism, sepsis, or leading to death.
"Treating pregnant women who have influenza with antiviral drugs can have substantial benefit in terms of reducing length of stay in the hospital," explained senior author Sandra S. Chaves, MD, MSc, of the CDC. "The earlier you treat, the better chances you have to modify the course of the illness." In an Infectious Diseases Society of America press release, Chaves recommends that antiviral treatment begin even before flu is confirmed.
The new report cites past studies finding that flu antiviral therapy is safe and beneficial for pregnant women.
For the current study, researchers used data from a nationwide flu surveillance network including 14 states, focusing on pregnant women hospitalized with laboratory-confirmed flu over four recent influenza seasons from 2010 to 2014. During the study period, 865 pregnant women were hospitalized with flu, with about 7% of those having severe illness.
Among those severely ill inpatients, researchers found that treatment with the antiviral drug oseltamivir within two days of the start of symptoms was associated with a median length of stay about five days shorter compared to similar patients treated later -- 2.2 days vs. 7.8 days.
While the hospital stay also was reduced in pregnant women hospitalized with less severe illness who were treated early, the difference was not as great, according to the study.
CDC researchers also made another critical point: Pregnant women hospitalized with severe flu illness were half as likely to have been vaccinated as women hospitalized with milder illness – 14% vs. 26%.
Flu vaccination is recommended for everyone 6 months of age and older, including pregnant women during any trimester of their pregnancy. In fact, some research has suggested that immunization during pregnancy protects not only the mother but also her newborn baby during the first six months of life.
New Guideline Issued for Emergency Treatment of Status Epilepticus
CINCINNATI – Status epilepticus, in which patients have continuous or rapid sequential seizure activity for 30 minutes or more, is a major medical emergency with a high potential mortality rate.
Emphasizing the importance of prompt and effective treatment, the American Epilepsy Society (AES) recently released a new guideline to help emergency physicians and other medical professionals treat patients more effectively. The guideline, which focuses specifically on convulsive status epilepticus because it is the most common type of status epilepticus and is associated with substantial mortality, was published in a recent issue of Epilepsy Currents, the AES journal.
Background information in the article notes that between 50,000 and 150,000 Americans have status epilepticus each year, and up to 30% of adults, although less than 3% of children, end up dying.
"This is a valuable new guideline for both children and adults that could change the approach many clinicians take in treating these seizure emergencies," said guideline author Tracy Glauser, MD, of Cincinnati Children's Hospital Medical Center's Comprehensive Epilepsy Center. "The goal of therapy is the rapid termination of the seizure activity to reduce neurological injuries and deaths."
After the stabilization phase, defined as 0-5 minutes of seizure activity and requiring standard initial first aid for seizures as well as initial assessments and monitoring, the guideline calls for a treatment algorithm comprising three phases:
- The Initial therapy phase (5-20 minutes of seizure activity), when it becomes clear the seizure requires medical intervention. A benzodiazepine (specifically IM midazolam, IV lorazepam, or IV diazepam) is recommended as the initial therapy of choice, given its demonstrated efficacy, safety, and tolerability.
- The second therapy phase (20-40 minutes of seizure activity) when response to the initial therapy can be assessed. The guideline suggests that reasonable options include fosphenytoin, valproic acid, and levetiracetam, offering no preference among them. Because of adverse events, IV phenobarbital is a reasonable second-therapy alternative if none of the three recommended therapies is available, according to the authors.
- The third therapy phase (40 or more minutes of seizure activity). The guideline recommends that, if second therapy fails to stop the seizures, treatment considerations should include repeating second-line therapy or anesthetic doses of either thiopental, midazolam, pentobarbital, or propofol, while continuing EEG monitoring.
Based on the cause of the event or the severity of the seizures, study authors point out, clinicians might go through the phases more quickly or even skip the second phase and move rapidly to the third phase, especially in sick or intensive care unit patients.
"In treating status epilepticus there is an overriding urgency to stop seizures before the 30-minute mark when seizure-associated neurologic injury can occur," guideline coauthor Shlomo Shinnar, MD, PhD, of Albert Einstein College of Medicine and Montefiore Medical Center, said in an AES press release. "This guideline supports an aggressive approach to treating status epilepticus and seeks to bring some structure to what can often be a chaotic and dire medical situation."
Infectious Disease in Older Americans Sends Many to ED
BOSTON – Despite common assumptions, most of the older adults presenting to the emergency department aren’t suffering heart attacks or other cardiac-related ailments.
In fact, according to a report in the Journal of the American Geriatrics Society, infectious diseases account for 13.5% of ED visits involving patients age 65 or older, which is a higher percentage than for emergency care sought for heart attacks and congestive heart failure combined.
The highest rate of ED visits for infectious diseases was among patients 85 years old and older, notes the study, which involved researchers from Harvard University and the University of Fukui Hospital in Japan.
The review found that lower respiratory tract infections, such as pneumonia, made up about a fourth of the ED visits for infectious diseases, with pneumonia itself accounting for 17.5% of those visits.
Lower respiratory tract infections also were responsible for 15% of the infectious disease-related deaths during ED visits and after admission.
Septicemia, meanwhile, was the diagnosis in 32% of infectious disease-related admissions and 75% of infectious disease-related deaths during ED visits and hospitalizations. Urinary tract infections accounted for 25.3% of the infectious disease ED visits.
For the study, researchers examined more than 3 million ED visits related to infectious diseases, with 57% resulting in hospitalizations in that group; the percentage of hospitalization went up to 66.5% for patients age 85 and older. Of those patients, 123,894, 4%, died during the ED visit or subsequent hospitalization.
Study authors point out that higher immunization rates for influenza and pneumonia could make a significant difference in morbidity and mortality related to infectious disease for older patients.
A recent study from the national Centers for Disease Control and Prevention says that the influenza vaccination rate was 71.5% and pneumococcal vaccination coverage was 61.3% among adults aged 65 and older in 2014.
While still lower than recommended, reported pneumococcal vaccination coverage (23-valent pneumococcal polysaccharide vaccine [PPSV23] and 13-valent pneumococcal conjugate vaccine [PCV13]) among older adults still was almost triple the 20.3% rate for adults 19–64 considered at high risk, the CDC said.
ED Mental Health Visits Increase for Young Adults After ACA Adoption
SAN FRANCISCO -- Emergency department visits for young adults, ages 19 to 25, might have decreased slightly overall following the implementation of the Affordable Care Act (ACA), but visits for mental illnesses and diseases of the circulatory system increased substantially among that age group.
That’s according to a study published online recently by Annals of Emergency Medicine.
"Increased health insurance coverage reduced ER visits by young people for conditions that can be treated in office-based settings, but the lack of mental health resources continues to bring these patients to the ER in ever larger numbers," explained study author Renee Hsia, MD, of the University of California San Francisco. "We also saw an increase in patients with diseases of the circulatory system, such as non-specific chest pain.”
On the other hand, Hsia noted a big decrease in ED visits for complications of pregnancy “which is important as it was among the top reasons they visited the emergency department prior to the implementation of the ACA."
To determine what effect the ACA had on patient visits, researchers conducted a before-and-after study in California, Florida, and New York. Patients age 19 to 25 were compared to patients 26 to 31 during the same time periods, September 2009 through August 2010 vs. January through December 2011.
The researchers analyzed 10,158,254 ED visits made by 4,734,409 patients. After the implementation of the 2010 ACA provision, young adults had a relative decrease of 0.5% ED visits per 1,000 people compared with the older group.
Results indicate that the rate of ED visits by young people decreased by 0.5% after ACA implementation. Yet, the relative risk of a young adult ever to visit the ED increased by 2.6% for mental illness and by 4.8% for diseases of the circulatory system such as cardiac dysrhythmias or nonspecific chest pain.
The relative rate of emergency visits decreased by 3.7% for pregnancy-related diagnoses, meanwhile, and by 3.3% for diseases of the skin, such as cellulitis and abscesses.
Overall, study authors note that only white and black young adults decreased their frequency in seeking emergency care, not Hispanics.
“Our results indicate that increased coverage has kept young adults out of the ED for specific conditions that can be cared for through access to other channels,” the article concludes. “As EDs face capacity challenges, these results are encouraging and offer insight into what could be expected under further insurance expansions from health care reform.”
"The troubling finding is that young adults were more likely to visit the emergency department for mental illnesses following expanded insurance coverage under the ACA," Hsia added in an American College of Emergency Physicians press release. "Significant barriers to care for mental health issues persist, leaving these patients little choice but to seek care in the only place they know they can get it: the ER."
UPCOMING [LIVE] WEBINARS
CMS Medical Records: What You Need to Know
Live: February 23 Credits: 1.5 CE
Give Falls the Slip: TJC & CMS Hospital CoPs & Standards
Live: February 29 Credits: 2 CE
Professionalism in Social Media: Guidelines for Healthcare Workers
Live: March 1 Credits: 2 CE
Increasing Patient Satisfaction & HCAHPS Scores Through Digital Dashboarding
Live: March 8 Credits: 1 CE
Hot Topics in Risk Management and Patient Safety
Live: March 15 Credits: 2 CE
Informed Consent: Meeting CMS, TJC, and DNV Requirements
Live: March 16 Credits: 2 CE
IV Medication & Blood Administration: Did Your Hospital get the Memo?
Live: March 17 Credits: 1.5 CE
Patient Rights: Complying with the CMS Hospital CoPs
Live: March 30 Credits: 2 CE
Safe Injection Practices and IV Push Guidelines:
Compliance with CDC and CMS Standards
Live: April 4 Credits: 2 CE
CMS CoPs for Critical Access Hospitals: The Intensive Series
Live: April 5, 12, 18 Credits: 6 CE
