ED Push - April 2016 First Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
New Guidance Provided on How EDs Should Deal with Elder Abuse
STANFORD, CA – Emergency physicians face a dilemma with elderly patients who are severely debilitated when they present for treatment. Are their symptoms caused by an underlying illness or are they victims of willful neglect or even unintentional neglect?
According to the level and type of neglect, clinicians might be obligated to report the case to adult protective services. And, being faced with that decision is not a rarity: Elder abuse has an estimated prevalence of 5% to 10% and has been linked to major adverse health outcomes, including dementia, depression, and mortality, according to recent articles published online by Annals of Emergency Medicine.
"Given the aging of the population, emergency physicians need to be prepared to balance their obligations to the patient by documenting findings, reporting suspicions and referring patients to appropriate agencies," explained lead author of one of the studies, Marguerite DeLiema, PhD, of the Stanford University Center on Longevity in Stanford. "Emergency physicians can also help prevent misunderstandings about elder neglect by encouraging patients to document care preferences, involve others in care planning and communicate with their caregivers about how to fulfill their wishes."
That article documented two case studies, one involving intentional neglect by a son who said he didn’t want to spend money on care for his father “because he is dying,” and another involving a family member who was overwhelmed by her father’s care.
Both patients had symptoms suggestive of neglect, according to the authors, but comprehensive review revealed many layers of complexity.
“We use these cases to illustrate an approach to the assessment of possible elder neglect in ED settings and how to intervene to ensure patient safety,” the researchers write. “We begin with a discussion of the differences between willful, unintentional, and unsubstantiated neglect by a caregiver and then describe when to suspect neglect by evaluating the elder, interviewing the caregiver and first responders, assessing the caregiver’s ability to meet the elder’s needs, and, if possible, obtaining medical history and information about the home care environment. These cases illustrate the importance of careful documentation in cases of suspected neglect to assist investigative agencies, reduce the risk of further harm, and improve patient outcomes.”
A second report defines elder abuse and neglect as “action or negligence against a vulnerable older adult that causes harm or risk of harm, either committed by a person in a relationship with an expectation of trust or when an older person is targeted based on age or disability.” The authors point out that mistreatment could include physical abuse, sexual abuse, neglect, psychological abuse, or financial exploitation, with many victims experiencing a combination of those.
Those researchers recommend a team-based approach across disciplines to identify elder abuse, including emergency medical providers, triage providers, nurses, radiologists and technicians, social workers, and case managers. Study authors emphasize that opportunities to detect abuse exist throughout an episode of emergency care, and involve everyone from paramedics and EMTs to social workers and law enforcement who intervene after a problem is identified.
"Currently, most victims of elder abuse and neglect pass through our emergency departments with a life-threatening condition unidentified," lead author of the second study, Tony Rosen, MD, MPH, of Weill Cornell Medical College in New York, said in an American College of Emergency Physicians press release. "A multi-disciplinary, team-based approach supported by additional research and funding has the potential to improve the identification of elder abuse and improve the health and safety of our most vulnerable patients."
Suicide Attempt, Ideation Patients Should Be Asked About Firearms in Home
AURORA, CO – Whether emergency physicians are too busy saving lives, uncomfortable with the questions, or simply skeptical about the approach, only about half ask suicidal patients if they have access to firearms or other methods of killing themselves at home, according to new research.
National guidelines recommend that ED physicians gather that information, according to a study published recently in the journal Depression and Anxiety.
For the study, University of Colorado Anschutz Medical Campus researchers interviewed 1,358 patients who had either attempted suicide or were thinking about it and sought treatment at one of eight EDs in seven states.
"We asked the patients about their access to firearms and then reviewed their charts," recounted lead author Emmy Betz, MD, MPH. “We found in about 50% of cases there is no documentation by the doctor that anyone asked the patients about firearms access. That means there is a large group of patients we are missing a chance to intervene for."
Results indicate that about 25% of potentially suicidal patients who said they had guns at home kept at least one of them loaded and unlocked. Overall, half of the patients surveyed had convenient access to guns, putting themselves at risk for future suicide attempts.
Among a subgroup of 337 patients discharged to home, 55% had no documentation of lethal means assessment, although 13% of them had one or more firearms at home. Among all of the participants who told staff they had one or more firearms at home, only 50% had documentation of assessment of lethal means access, according to the study.
"Multiple ED visits appear to be a risk factor for suicide and many suicide victims are seen in the ED shortly before death," study authors write. "Based on models using national suicide statistics, ED-based interventions might help decrease suicide deaths by 20% annually."
The article cites previous studies suggesting, however, that ED doctors are skeptical about the effectiveness of that type of intervention.
"This rate of assessment falls short of national guidelines recommending that all suicidal patients receive counseling about reducing access to firearms and other lethal means," Betz said in a University of Colorado Anschutz Medical Campus press release. "Lethal means assessment is important for both overall risk assessment and for safety planning for patients being discharged."
Betz suggested that ED staff involve patient families, asking them to lock up firearms or remove them from the house.
"It is legal and appropriate to ask about this when it is relevant as it is in the case of suicide attempts or suicidal ideation," Betz said. "Do it in a respectful, non-judgmental way and it will usually be well-received. Still, there isn't a lot of training on this. As a result, we are missing the chance to save a lot of lives."
Most Kidney Transplant Patients Visit an ED Within Two Years of Procedure
CLEVELAND – More than half of the 17,000 patients receiving kidney transplants annually in the United States can expect to end up in the emergency department in the two years after their surgery.
In light of that, a study appearing in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN) calls for more effort to coordinate care for those patients.
Noting that little information is available on the incidence and risk factors associated with ED visits among kidney transplant recipients, a study team led by Cleveland Clinic researchers focused on 10,533 kidney transplant recipients from California, New York, and Florida between 2009 and 2012.
Results indicate that the cumulative incidence of ED visits at 1, 12, and 24 months was 12%, 40%, and 57%, respectively, with a median time of 19 months.
Overall, 57% of the kidney transplant recipients visited an ED within two years, and nearly half of those ED visits, 48%, led to hospital admission.
Risk factors for those visits include younger age, females, black and Hispanic race/ethnicity, public insurance, depression, diabetes, peripheral vascular disease, and frequent use of EDs prior to transplantation.
"These data provide fundamental baseline information concerning the scope and factors of emergency department visits and potential interventions and target populations for future study," said lead researcher Jesse Schold, PhD. "It is crucially important that emergency department clinicians are cognizant of the specific issues pertinent to transplant recipients given unique medical issues. Moving forward, tailored interventions, particularly to patients and institutions with high rates of emergency department visits following discharge, may be important."
In an accompanying editorial, Lorien Dalrymple, MD, MPH, and Patrick Romano, MD, MPH, of the University of California at Davis, called the study "important as it extends prior findings that were limited to single centers and addresses an understudied topic."
African American Patients Bear the Brunt of California ED Diversion
SAN FRANCISCO – Who suffers the most when your hospital emergency department has to go on diversion?
A study in the journal BMJ Open suggests the answer could be African American patients suffering heart conditions. A study from the University of California San Francisco reports that those patients are more likely than white patients to have their ambulance diverted to another hospital due to overcrowding in their nearest ED.
The report also emphasizes that, when the nearest hospital had significant ambulance diversion, black patients had a lower chance of receiving specialized cardiac care and lower one-year survival rates. That’s in line with previous research about ambulance diversion and its association with worse long-term mortality, study authors point out.
“The take-home findings from this study are two-fold,” said co-author Renee Hsia, MD, professor of emergency medicine and health policy at UCSF. “First, we now better understand the mechanisms behind emergency department crowding and how it affects patients. Not only are crowded hospitals less able to deliver high-quality care, but even sick patients get diverted to hospitals with less technology. On top of that, they are less likely to receive appropriate treatment.
“Secondly, we have definitive evidence that minority-serving hospitals, or hospitals that serve a high proportion of black patients, tend to experience higher levels of emergency department crowding,” Hsia said.
For the study, researchers linked daily ambulance diversion logs from 26 California counties to Medicare patient records with acute myocardial infarction between 2001 and 2011. Differences in access, treatment, and outcomes between black and white patients at different stages of ambulance diversion were documented.
Of the 30,000 patients in the sample, half experienced no diversion, 25% experienced six hours or less of diversion, 15% had 6-12 hours of diversion, and 10% had more than 12 hours of diversion.
“Hospitals serving high volume of black patients spent more hours in diversion status compared with other hospitals,” according to the report. It also notes that patients facing the most ED diversion had the lowest probability of being admitted to hospitals with cardiac technology compared with those facing no diversion, by 4.4% for cardiac care intensive unit, and 3.4% for catheterization laboratory and coronary artery bypass graft facilities. In addition, those patients experiencing increased diversion had a 4.3% decreased likelihood of receiving catheterization and 9.6% higher one-year mortality.
“Our hope is that we can take this evidence and translate it into change at the systems level,” Hsia said. “While focusing efforts to decrease emergency department crowding is necessary in all hospitals, it might be more ‘bang for the buck’ if we want to make a dent in decreasing disparities by targeting efforts in minority-serving hospitals.”
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