ED Push - April 2016 Second Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Why Burgers from a Very Clean Grill Can Be Dangerously Crunchy
COLUMBIA, MO – Guests at a cookout might be concerned that the barbecue grill isn’t clean enough. Emergency physicians know, however, that too aggressive cleaning can also create health problems.
Just in time for summer grilling season, a study published in Otolaryngology-Head and Neck Surgery examines the incidence of injuries caused by ingesting wire bristles from grill cleaning brushes.
Researchers from the University of Missouri School of Medicine reviewed the dangers when wire-bristle grill brushes, used for cleaning grill grates, lose bristles during scrubbing. If the bristles adhere to the grill, become stuck to food, and then accidentally are ingested, serious injuries can result.
For the study, researchers reviewed literature and used the Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) and the consumer reported injury database SaferProducts.gov to estimate emergency department visits for wire bristle injuries between 2002 and 2014.
Examination of the NEISS revealed 43 cases, which extrapolated to an estimated 1,698 emergency department (ED) visits nationwide, with an average patient age of 30 years, according to the study.
The most common site of injury was the oropharynx, with 53.4%in the NEISS database, and 30.5% in the literature review. In the consumer-reported SaferProducts.gov database, however, injury was most commonly to the oral cavity, 37.5%, the researchers report.
Most, nearly 70%, of the patients documented in the NEISS were treated in EDs, with case counts highest in July, followed by June and August. Study authors caution, however, that estimates don’t include injuries treated at urgent care facilities or other outpatient settings.
"The issue is likely underreported and thus underappreciated," lead author C.W. David Chang, MD, said in an American Academy of Otolaryngology - Head and Neck Surgery press release. "Because of the uncommon nature of wire bristle injuries, people may not be as mindful about the dangers and implications. Awareness among emergency department physicians, radiologists, and otolaryngologists is particularly important so that appropriate tests and examinations can be conducted."
Study authors recommend that caution be exercised when cleaning grills with wire-bristle brushes – or, even better, that alternative cleaning methods be employed – and that cooking grates be inspected prior to putting food on the grill.
Shared Decision-making Reduces Risks of Chest Pain Overtreatment
ROCHESTER, MN – Here’s a suggestion on how to avoid overtreatment of low-risk chest pain in the emergency department: Engage in shared decision-making with patients, which, according to new research, results in better care and more efficient use of resources.
A presentation at the American College of Cardiology's 65th Annual Scientific Session in Chicago reported that low-risk chest pain patients who talked through treatment options with an emergency physician showed improved knowledge of their health status and follow-up options, compared with patients who received standard counseling.
Noting that about 8 million ED visits in the United States each year are related to chest pain, background information in the Mayo Clinic-led study states that more than 90% of those patients are not experiencing a heart attack. At the same time, over-evaluation of low-risk patients can lead to false-positive test results, unnecessary hospital admissions, and exposure to ionized radiation.
Researchers tested their theory that a way to potentially decrease physician decisions to over-treat would be to engage patients in shared decision-making.
"An electrocardiogram and blood tests can tell us if a patient is having a heart attack,” explained lead author Erik Hess, MD. “Further testing may be needed to tell us if a patient faces an increased risk of heart attack in the near future. We wanted to know if there is value in discussing this further testing with patients."
For the study, which included about 900 patients visiting six EDs in five states, half of the patients --mean age 47.6, mostly female, with nearly half having hypertension and a family history of cardiac disease -- were randomly assigned to receive a physician discussion using Chest Pain Choice, the first patient-oriented tool designed to help shared decision-making between physicians and patients with chest pain. As part of that, patients were shown one-page information sheets with descriptions and graphics depicting a patient's specific risk, such as a 2% risk of having a heart attack in the next 45 days, as well as next steps for care.
Patients receiving the Chest Pain Choice information were able to correctly answer 53% of questions on a survey about their knowledge of risk and options, compared with 44.6% of the patients receiving standard physician consultation.
The patients receiving Chest Pain Choice also were more likely to say they would recommend the way they discussed care and options with their ED physicians than those who received standard care -- 68.9% vs. 61.2%.
"This trial shows that patient engagement in care can be beneficial to the patient's understanding and treatment, and can lead to better care and more efficient use of resources," Hess said in a Mayo Clinic press release. He emphasized that using Chest Pain Choice was associated with no major adverse heart events and led to a significantly lower proportion of patients receiving a stress test.
Widespread Screening in ED Detects Nearly Double the Suicidal Patients
WORCESTER, MA – Almost universal suicide risk screening conducted by emergency department nurses nearly doubled the number of patients who were positively identified as having thought about or attempted suicide, according to a new study.
The report published recently in the American Journal of Preventive Medicine noted that detection of suicide risk rose from 2.9% to 5.7% when screening among 236,791 patients went from 26% to 84%.
“Our study is the first to demonstrate that near-universal suicide risk screening can be done in a busy ED during routine care,” said lead author Edwin Boudreaux, PhD, of the University of Massachusetts (UMass) Medical School.
The research was part of the $12 million Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study. Nurses at eight participating EDs in seven states were trained to administer a brief patient screening tool focusing on three suicide risk factors: depressive symptoms, active suicidal ideation, and lifetime suicide attempts. A positive screen is defined as any individual who either confirmed active suicidal ideation, or reported a suicide attempt within the six months prior to the ED visit.
The study period from 2009 through 2014 encompassed three phases:
- Treatment as Usual (Phase 1);
- Universal Screening (Phase 2); and
- Universal Screening + Intervention (Phase 3).
Data was collected during peak hours seven days of the week.
“The patients we identified through screening received additional evaluation and intervention resources they otherwise would not have received,” Boudreaux, professor of emergency medicine, psychiatry, and quantitative health sciences and vice chair of research for the Department of Emergency Medicine, said in a UMass press release. “In fact, with screening we identified a subset of patients whose suicidality was serious enough to warrant psychiatric inpatient treatment. What would have happened to them if they had been discharged? The conventional wisdom is that at least some of those individuals would have tried to kill themselves.”
An additional 90% of patients with positive screens were discharged with resources, including lists of community-based services, a self-help safety plan, and a wallet card with local suicide prevention lifeline numbers.
In the study’s final phase, patients with positive screens who agreed to participate received, after discharge, more intensive intervention through structured telephone calls with trained nurses.
“Universal suicide risk screening in the ED was feasible and led to a nearly twofold increase in risk detection,” study authors conclude. “If these findings remain true when scaled, the public health impact could be tremendous, because identification of risk is the first and necessary step for preventing suicide.”
ED-SAFE is funded by an initiative of the National Institute of Mental Health to develop evidence-based practice guidelines that will optimize the ED as an important setting in which to increase suicide risk detection and suicide prevention.
How Do Revised Guidelines Affect Cardiac Arrest Patient Survival?
DENVER – While resuscitation guidelines previously called for up to three successive or “stacked” shocks with minimal time delays between defibrillation attempts for cardiac arrest patients, resuscitation guidelines were revised in 2005 to support single shock protocols with two minutes of chest compressions between defibrillation attempts to minimize interruptions in compressions.
A new study published in The BMJ Today raises questions about the delay in giving the second shock, suggesting it is not associated with improved survival.
Veterans’ Affairs Colorado Health Care System-led researchers said they conducted the study because of the lack of data on how those changes affect survival for patients with cardiac arrest in hospitals.
For the retrospective cohort study looking at 172 hospitals in the United States participating in the Get With The Guidelines-Resuscitation registry from 2004-12, the researchers examined trends in the time interval between first and second defibrillation attempts among 2,733 patients suffering cardiac arrest.
Among 2,733 patients with persistent ventricular tachycardia or ventricular fibrillation (VT/VF) after the first defibrillation attempt, 1,121 (41%) received a deferred, defined as more than one minute, second attempt.
In line with the guidelines, results indicate that the proportion of patients with a deferred second defibrillation attempt doubled from 26% in 2004 to 57% in 2012.
Compared with early second defibrillation, defined as less than a minute, unadjusted patient outcomes were significantly worse with deferred second defibrillation: 57.4% vs. 62.5% for return of spontaneous circulation, 38.4% vs. 43.6% for survival to 24 hours, and 24.7% vs. 30.8% for survival to hospital discharge.
After risk adjustment, study authors determined that deferred second defibrillation was not associated with survival to hospital discharge, with an adjusted risk ratio of 0.89.
A second study, led by researchers from Beth Israel Deaconess Medical Center in Boston, suggests that early administration of epinephrine in hospital is associated with poorer outcomes in patients with cardiac arrest and a shockable rhythm.
The international study team sought to reconcile different guidelines for use of epinephrine, employing the Get With The Guidelines data for nearly 3,000 patients with cardiac arrest at more than 300 U.S. hospitals. More than half, 51%, of patients received epinephrine within two minutes after the first defibrillation, contrary to current guidelines.
Results indicate that receiving epinephrine at that point was associated with a decreased chance of a good outcome, including survival to hospital discharge, compared with patients who were not given epinephrine within this time period.
Authors of both studies point out that their research was observational, so no firm conclusions can be drawn about cause and effect.
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