ED Push - July 2016 First Issue

EDs Have the Most Complex Work Schedules to Balance

SAN FRANCISCO – While this might not come as any surprise to emergency medicine physicians trying to remember when they next need to show up for work, new research on medical shift scheduling trends shows that EDs in the United States must balance the most complex sets of staffing rules and monthly requests of any specialty in the medical industry.

The report, 2016 Physician Scheduling Complexity by Specialty, analyzed rules and requests used in 5,547 department schedules across 57 medical specialties. The analysis was created by Lightning Bolt Solutions, which develops scheduling software.

Here’s how complex physician schedules in EDs can be: The software must apply an average of 62 repeating scheduling rules (i.e., physicians can’t work two 12-hour shifts in a row) and 276 monthly schedule requests, which are not pattern-based like rules and can include vacation time or the staffing of locum tenens or moonlighters with variable schedules.

The report notes that pulmonology has the most repeating scheduling rules, 134, more than double that of emergency medicine, but far fewer monthly schedule requests. Schedules for office-based physician specialties were less complicated in general, according to the report.

“Emergency medicine department schedulers are juggling more variables than there are atoms in the universe,” explained Suvas Vajracharya, PhD, founder and CEO of Lightning Bolt Solutions. “Keeping emergency rooms staffed with the right balance of physicians and locum tenens to meet patient demand 24/7 is essentially rocket science.”

The issue, Brian Lahmann, emergency medicine physician at Reading Hospital, part of Reading Health System, in West Reading, PA, added in a Lightning Bolt press release, is that EDs must be staffed 24 hours a day, 365 days a year, taking into account cyclical patient volume patterns and variable patient acuity. To meet such demand, many emergency departments staff separate lower and higher acuity areas.

“Thus,” Lahmann emphasized, “emergency departments have to schedule multiple providers who may have similar and different skills and abilities to care for all of these patients in various areas.”

After emergency medicine, the most complex physician specialties to schedule were hospital medicine, OB-GYN, pulmonology, anesthesiology, surgery, radiology, primary care, cardiology, pediatrics, and nephrology.

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Most Snakebites Unexpected, Occurring Without Intentional Contact

WEST HARTFORD, CT – When a patient presents to the emergency department with a poisonous snakebite, emergency physicians might wonder how that occurred and whether the injury calls into question the patient’s judgment.

New research published in the journal Wilderness & Environmental Medicine provides some answers. An analysis of media reports about snakebites in the United States suggests that most are likely “legitimate,” i.e., occurring by surprise, without intentional contact, in a natural setting.

Previously, it was believed that the majority of snakebites occurred when humans were handling the reptiles in captivity or attempting to kill or move a wild snake.

Interestingly, University of Hartford researchers found that media coverage detailed victim circumstances better than current quantitative data.

"Examining media-reported snakebite accounts provides a novel way to assess snakebite patterns in the United States," explained co-investigator Stephan Bullard, PhD. "Clinical reports tend to contain minimal personal detail, but a great deal of information about the pathologic effects and treatment of snakebites. Media reports vary widely, but are generally human interest stories that extensively detail the victim's activities leading up to the bite and usually contain little information regarding medical implications of the bite."

For the study, researchers looked at 332 media-reported bites from 2011-2013 and found that 307 (92.4%) occurred under natural conditions, while only 25 bites happened in captive-care situations. Most, 67.9%, of the total bites were found to be legitimate, meaning the victim was unaware of the snake's presence. The others were labeled as “illegitimate” bites that resulted from the purposeful handling of the snake.

Results of the media review also indicate that men were much more likely to be bitten by a snake, accounting for 67.1% of the victims in the study. The results also suggest that the location of the bite on the body reliably indicates whether or not the bite was legitimate: Legitimate bites more frequently occurred on the lower extremities, and illegitimate bites occurred more often on the hands and fingers.

A slight majority of the victims, 54%, reported walking or hiking when bitten, and 40.2% were bitten when they placed a body part in an area they could not see, such as while gardening or reaching into a woodpile.

Most of the bites were from rattlesnakes and copperheads, with bites from cottonmouths and coral snakes much less common. The review also gave credence to a theory that snakes release more venom the more threatened they feel.

"Eight of the 10 fatalities resulted from intentional, extended interaction with the snake," co-investigator Dennis K. Wasko, PhD, said in an Elsevier Health Sciences press release. "Although this is a relatively small sample size, these patterns support previous findings that snakes assess threat risks and meter their venom accordingly. Startled snakes frequently at first inflict dry bites in which little or no venom is injected, whereas direct restraint or repeated contact induces a defensive release of more venom."

An estimated 8,000 snakebites occur annually in the United States, according to background information in the article.

"Future efforts should focus on determining more about the specific triggers of snakebites, especially under natural conditions,” Bullard said. “A comprehensive, nationwide database of human envenomation by snakes is also needed for future study.”

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Life-Saving Procedures Used Less Often in Women with Cardiac Arrest

NEW YORK – Women treated for cardiac arrest in a hospital setting are less likely to survive, possibly because they also receive fewer potentially life-saving procedures, according to a new study.

Angiography and angioplasty are both used less often in women with the emergency condition, according to new research in Journal of the American Heart Association, the Open Access journal of the American Heart Association/American Stroke Association.

The Weill Cornell Medical College-led study notes that procedures such as those have helped increase cardiac arrest survival rates overall. "But the troublesome part of our paper is that just as with many other treatments, we're still not doing as good a job with women as men. Women tend to get less immediate care when time is essential,” said lead author Luke Kim, MD.

The study is touted as the first to report sex-based disparities across a representative spectrum of cardiac arrest patients from more than 1,000 U.S. hospitals nationally. Over the decade-long study, in-hospital death rates fell for both sexes, but remained higher for women – 64% for women vs. 61% for men.

For the study, researchers using the Nationwide Inpatient Sample analyzed more than 1.4 million cases in which cardiac arrest patients were transported alive to acute-care hospitals from 2003 through 2012, during which the number of cardiac arrests increased by 14%.

After adjusting for factors including patient age, health, hospital characteristics, and previous cardiac procedures, researchers also found that women who had a cardiac arrest from a shockable rhythm were:

• 25% less likely to receive coronary angiography;
• 29% less likely to have angioplasty, also known as percutaneous coronary intervention (PCI);
• 19% less likely to be treated with therapeutic hypothermia.

Women in the study group were older than the men and were less likely to have been previously diagnosed with coronary artery disease. They also were more likely to have such comorbidities as congestive heart failure, high blood pressure, obesity, and other issues, and to have cardiac arrest caused by problems other than a blood vessel blockage, such as pulmonary embolism.

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CT Scans Present Higher Risk of Cancer Than Clinicians Realize

SASKATOON, CANADA – Emergency department staff and other healthcare professionals aren’t always aware enough of how diagnostic tools such as computed tomography (CT) scans affect patients’ lifetime malignancy risk, according to a new study.

A Canadian study in the Journal of Medical Imaging and Radiation Sciences was based on a survey of physicians, radiologists, and imaging technologists regarding their beliefs about radiation exposure from CT. Results indicate that, while most respondents recognized an increased risk of cancer from CT, many underestimated the actual radiation dose as well as the dangers of ionizing radiation.

For the study, researchers from the University of Saskatchewan surveyed medical professionals in that area, finding that 73% of physicians, 97% of radiologists, and 76% of technologists correctly identified that there is an increased cancer risk from one abdominal-pelvic CT.

Only 18% of physicians, 28% of radiologists, and 22% of technologists were able to correctly identify the dose in relation to chest X-rays, however. The dose was accurately estimated or overestimated by 48% of physicians, 78% of radiologists, and 63% of technologists, while the rest underestimated the dose level.

"Underestimating radiation dose from a CT scan is more concerning than knowing the exact dose level, particularly when it is a vast underestimation, as this may lead to minimization of the risk estimate when considering a test," explained lead author David Leswick, MD, FRCPC.

The study points out that, measured in millisieverts (mSv), the average radiation dose from an abdominal-pelvic CT is 10 mSv, compared to 0.02 to 0.2 mSv from one chest X-ray, meaning that a radiation dose from a CT scan is best approximated as between the dose from 100-250 chest radiographs.

"Although risk from radiation dose levels in the range of medical imaging procedures is small, it is real as evidenced from atomic bomb survivors and nuclear industry workers showing significantly increased risk of malignancy after exposure to doses in the range of diagnostic CT," Leswick said in a University of Saskatchewan press release. "The risk of fatal malignancy may be as high as 1 in 1,000 for a 10-mSv exposure (approximate dose of an abdomen-pelvis CT). This risk is significant on a population basis, with up to 2% of cancers in the United States population possibly attributable to CT."

Most, 93%, of survey respondents said they were interested in radiation dose feedback when considering ordering a CT scan. Study authors note that automated dose calculation software and radiology information systems can be integrated into electronic ordering, which would give doctors immediate access to information when considering ordering a scan.

The study also uncovered some confusion regarding radiation exposure from magnetic resonance imaging (MRI) and ultrasound, which do not employ ionizing radiation. The survey found that 20% of physicians, 6% of radiologists, and 7% of technologists attributed radiation exposure to MRIs, and 11% of physicians, 0% of radiologists, and 7% of technologists believed that an ultrasound used radiation.

"Belief that ionizing radiation is utilized by ultrasound and MRI is troubling, as it may result in underutilization of these imaging modalities because of unfounded radiation concerns," Leswick.emphasized.

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