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Discharge Considerations After Minor Head Injuries

Discharge Considerations After Minor Head Injuries

In elderly patients suffering a fall, long-term anticoagulation has been shown to increase the incidence of intracranial hemorrhage (ICH) and mortality. Patients who receive treatment with anticoagulants have a higher risk for bleeding and can sometimes have serious outcomes after experiencing even relatively minor head injuries. Given the increasing number of elderly patients seen in EDs and the increase in concomitant anticoagulant use, the clinical dilemmas surrounding these patients have become more relevant. Several clinical decision rules have been created to help determine which head injury patients require a head CT scan, but these rules do not apply to anticoagulated patients. “There is some controversy surrounding the utility of head CT in allowing safe discharge dispositions for anticoagulated patients who suffer minor head injuries,” says Samuel M. Keim, MD, MS. Questions remain about whether or not a period of observation or routine serial CT scanning is warranted for these patients. A Closer Look In the Journal of Emergency Medicine, Dr. Keim and colleagues published a critical appraisal study that examined the risks of delayed ICH in anticoagulated patients with minor head injury and a normal initial head CT scan. The researchers reviewed four observational studies that investigated the outcomes of anticoagulated patients who presented to EDs after minor head injuries. In these observational studies, most patients who had a delayed ICH required no neurosurgical intervention and had no adverse outcome documented. The overall incidence of death or neurosurgical intervention ranged from 0% to 1.1% among the patients investigated. However, the studies did not clarify which patients were at highest risk. “Overall, the literature varied greatly but doesn’t support the...
A Look at Non-Urgent ED Visits & Resource Utilization

A Look at Non-Urgent ED Visits & Resource Utilization

As healthcare spending in the United States continues to rise substantially each year, policymakers have advocated for strategies to reduce what they deem as “unnecessary” ED visits as a way to generate cost savings. “When patients come to the ED and are classified at triage as non-urgent, payers often consider these visits unnecessary,” explains Adit A. Ginde, MD, MPH. “It has been argued that similar medical services could be provided at different sites of care, perhaps at a lower cost. The problem is that we don’t have an adequate definition of what constitutes non-urgent visits.” An In-Depth Analysis Some studies indicate that nearly one-third of ED visits could be classified as non-urgent. However, few studies in the current literature describe the resource needs and disposition of patients presenting to EDs with non-urgent triage acuity. To address this research gap, Dr. Ginde and colleagues published a study in the Western Journal of Emergency Medicine that used retrospectively analyzed data from the 2006-2009 National Hospital Ambulatory Medical Care Survey. These data were used to compare resource utilization of ED visits that were characterized as non-urgent at triage with visits in which there were higher triage acuity levels. Resource utilization included factors such as diagnostic testing, treatment, and hospitalization within each acuity categorization. “One of our key findings was that about 10% of ED visits in the U.S. were categorized as non-urgent,” says Dr. Ginde. “That means that about 13 million of the 130 million annual ED visits each year may be considered non-urgent.” However, most non-urgent visits (nearly 88%) had at least one intervention in the ED, which included imaging, diagnostic...

What’s the Point of Medical Licensing?

A surgeon emailed me the following:. OK, I know this is radical but consider my argument… Medical licensing protects no one and costs physicians hundreds to thousands of dollars each year. If a physician is negligent, can the injured party sue the state that licensed him? I’m guessing not. When I moved to my current location, I had to send lots of documentation to the state medical board so they could verify that I was a true and competent surgeon. I provided my employer with the same info so they could also verify my credentials. Now my employer can and will get sued if I commit a negligent act and absolutely should verify my credentials prior to handing me a scalpel. But the state? Its license is useless. Most people choose a surgeon based on recommendations and word-of-mouth reputation, and these are by far better indicators of quality than any credentialing board. Nobody asks to see my license, and, even if they did, it would not protect them any more than their trust in the health system in which I work. If I was in private practice and had my license displayed on my wall, it may give some reassurance to my patients, but it does not say anything about the quality of my work. Most doctors who really screw up due to negligence are licensed by the state. I contend again, that word of mouth and reputation are the best indicators of a surgeon’s ability, anything beyond that is useless. Caveat emptor, “let the buyer beware” remains the mantra of the informed consumer. Thanks for letting me vent....
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