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The ED’s Expanding Role in Hospital Admissions

Although research has focused heavily on increased use of EDs, little attention has been paid to the changing role that these facilities play in the entire healthcare system. In a study published in the New England Journal of Medicine, Arjun Venkatesh, MD, MBA, and I examined the proportion of hospital admissions that came through the ED to determine trends in general use and to confirm the experiences of emergency physicians and hospital administrators in these situations. ED Admissions on the Rise Focusing on the 13 conditions for which patients are most commonly admitted to the hospital, our analysis revealed that hospital admissions increased by 15.0%, rising from 34.3 million in 1993 to 39.5 million in 2006, but admissions from the ED increased by 50.4% (rising from 11.5 million to 17.3 million) during that same timeframe. The proportion of all inpatient stays that came through the ED increased significantly, rising from 33.5% to 43.8%. Only one of the 13 conditions studied in our analysis—coronary atherosclerosis— had a proportion that didn’t increase. More and more patients are being evaluated for coronary atherosclerosis in the ED and not admitted thanks to newer rapid “rule-out” protocols and ED-based chest-pain observation units. Our observation that more admissions are coming through the ED is likely due to several factors, most notably the advancing diagnostic and treatment capabilities of EDs and the convenience that EDs offer. As rapid and accurate diagnoses and treatments become standard, evaluating symptoms like chest pain and shortness of breath have become de facto reasons for ED referral. It has also become more difficult for outpatient providers to admit people directly to...
Gastric Bypass Surgery for Mild Obesity in Diabetics

Gastric Bypass Surgery for Mild Obesity in Diabetics

In 2003, a study of more than 1,000 patients who underwent gastric bypass found that one-third of those with diabetes at baseline had normal blood sugars after their surgery and didn’t need medication when they were discharged from their surgical hospitalization. This finding sparked further exploration into the effects of gastric bypass surgery on weight-independent, antidiabetes mechanisms. Testing a New Population In Diabetes Care, my colleagues and I had a study published that explored the use of Roux-en-Y gastric bypass (RYGB) as a primary modality to treat type 2 diabetes in patients for whom weight loss was not the primary objective. When we began the study, clinical observations had suggested that diabetes remits in about 80% of patients who undergo gastric bypass. What we didn’t know was the durability of that effect or what the outcomes would be in patients who weren’t severely obese. In our analysis, we selected 66 consecutive patients with type 2 diabetes who were mildly obese (BMI between 30 kg/m2 and 35 kg/m2) to undergo RYGB. These patients were prospectively studied for up to 6 years. At baseline, they had an average A1C of 9.7% despite being on insulin or at least two diabetes medications. At 6 months after RYGB, the average A1C level decreased to 6.5% and continued to decrease to 6.1% at 6 years, with 100% follow-up in this cohort. At the latest follow-up, 88% of patients had achieved diabetes remission, which was defined as having an A1C of 6.5% or less and being off all diabetes medications. We also found that â-cells were nearly five times more sensitive to blood sugar, on...
Top 10 Specialties Sued: 2013 Malpractice Report

Top 10 Specialties Sued: 2013 Malpractice Report

Nearly 1,400 physicians who were sued for medical malpractice share their experience in Medscape’s recent Malpractice Report. According to the report, the top 10 medical specialties experiencing the most lawsuits were: Most malpractice claims against primary care physicians are a result of missed diagnoses, particularly of cancer and myocardial infarction in adults and meningitis in children, as well as medication errors. Other highlights from the malpractice report include: 35% of lawsuits were “failure to diagnose” (17% “failure to treat”) 74% of physicians were surprised to be sued 24% of physicians sued were dismissed prior to deposition –  45% went to depositions –  21% went all the way to trial 61% took up to 2 years to conclude 57% of plaintiffs received no monetary award –  18% received up to $100,000 –  16% received up to $500,000 –  2% received over $2 million 62% of responding physicians said the lawsuit result was fair. In almost all cases, the insurer paid the full payout amount. 29% of physicians said they no longer trust patients and treat them differently. 93% of sued physicians said saying “I’m sorry” would not have helped. Respondents to the malpractice survey advise other doctors to: follow up even when you don’t think you have to; practice more defensive medicine; document more often and more thoroughly; and get rid of rude, demanding, noncompliant patients. Click here to view the full Malpractice Report by Medscape....

Wisconsin Informed Consent Law is Ill-Advised

I normally wouldn’t do this but you need to see excerpts from an article in the Wisconsin State Journal to understand the nature of this case. I have abridged as much as possible. Thomas Jandre was driving to a job site when the left side of his face started drooping. He began drooling, his speech became slurred and he felt dizzy and weak in his legs. He went to the emergency room at St. Joseph’s Hospital in West Bend. Dr. Therese Bullis did a physical exam to rule out a stroke. She ordered a CT scan to rule out a hemorrhagic stroke. To check for an ischemic stroke, from a clot, she used a stethoscope to listen for unusual blood flow in his carotid artery. She diagnosed Jandre with Bell’s palsy, inflammation of a nerve that controls facial movement. Eleven days later, Jandre had a massive stroke that caused permanent damage to the left side of his body. An ultrasound showed the carotid artery along his neck was 95 percent blocked. Bullis was negligent in not telling Jandre he could have had a carotid ultrasound when she saw him, the Wisconsin Supreme Court ruled in April. The test might have led to treatments to prevent the stroke. The supreme court affirmed an appeals court decision that upheld a $2 million jury award in 2008 to Jandre, now 57, whose stroke occurred in 2003. The jury said Bullis wasn’t negligent in her diagnosis of Bell’s palsy but found her negligent in her duty of informed consent because she failed to discuss the carotid ultrasound. The decision “leaves physicians in the...
The Impact of Depression on ED Stays in ACS Patients

The Impact of Depression on ED Stays in ACS Patients

Studies suggest that about 30% of patients with acute coronary syndrome (ACS) experience symptoms of depression during hospitalization. These patients are nearly twice as likely to die from ACS or have recurrent cardiac disease when compared with those who aren’t depressed. The ED is often the first point of contact for treating ACS patients, and recent research suggests that psychosocial factors may impact aspects of care in the ED, including length of stay (LOS). Depression, ACS, & LOS It has been hypothesized that longer ED LOS may be associated with adverse clinical outcomes for those with ACS, especially among those with depression. In a recent issue of BMC Emergency Medicine, my colleagues and I sought to determine if depressed ACS patients experienced different ED care than those without depression. After reviewing data from 120 participants, we found that currently depressed ACS patients spent an average of 5.4 more hours in the ED than those who had never been depressed. Not surprisingly, our study also revealed that presentation to the ED during off-peak hours was associated with longer ED LOS. Interestingly, no significant associations were observed with other demographic variables that might be expected to influence ED LOS, including race, ethnicity, or neighborhood income. Furthermore, these variables did not appear to account for the association between depression and ED LOS. Making Interpretations Data from our study are preliminary, but indicate that there is likely an association between depression and longer ED LOS. There are several possible explanations for this finding. Depression may influence how ACS patients present to the ED, report their symptoms, recruit family members or friends to accompany...

Oncology Update eBook

We are proud to present this monograph featuring several features that are applicable to oncologists, including articles on robotic cancer surgery, nutrition and exercise in cancer survivors, and CRC screening guidelines. Created with the assistance of key opinion leaders and experts in their respective fields, these articles discuss challenges and opportunities in oncology and strategies to positively change current...
Dedicated Hospital Observation Units to the Rescue

Dedicated Hospital Observation Units to the Rescue

Along with growing demand, rising costs and lower payments have threatened the financial viability of many hospitals, resulting in ED and hospital closures and a mismatch of supply and demand for acute care services. Considering these recent trends, efforts to improve healthcare efficiency are shifting focus toward enhancing hospital efficiency. Delivering care in observation units is an alternative to admitting patients who cannot be safely discharged to their homes following ED visits. Observation units are dedicated spaces where patients receive care, usually for up to 24 hours. Studies suggest that care in observation units is equal or better in terms of quality and lower in cost than inpatient care for specific conditions. The strongest evidence supporting the benefits of observation care is specific to care delivered in dedicated observation units. Unfortunately, only one-third of hospitals deliver this care in an observation unit. Potential Cost Savings with Observation Unit Use Understanding the financial impact of increased use of observation unit care is important for healthcare delivery redesign. In an issue of Health Affairs, my colleagues and I published a study that quantified the potential cost savings from decreasing avoidable inpatient admissions by using dedicated observation units more frequently in hospitals that could justify opening one. We performed a systematic literature review to find the average cost savings per observation unit visit and then used a Monte Carlo simulation model to estimate the number of avoided inpatient admissions and associated cost savings at the hospital and national level. According to our results, wider use of hospital observation units could save the healthcare system billions of dollars each year. The average amount...
The ABI: Standardizing Measurements & Interpretations

The ABI: Standardizing Measurements & Interpretations

When the ankle-brachial index (ABI) emerged in 1950, it was initially proposed for use as a noninvasive diagnostic tool for lower-extremity peripheral artery disease (PAD). Since then, studies have shown that the ABI is an indicator of atherosclerosis at other vascular sites, making it a useful prognostic marker for cardiovascular events and functional impairment, even in the absence of symptoms of PAD. In an issue of Circulation, the American Heart Association (AHA) released a scientific statement with standardized recommendations for measuring and monitoring the ABI. The recommendations provide protocols and thresholds for use in PAD and cardiovascular risk prediction, according to Michael H. Criqui, MD, MPH, FAHA, who co-chaired the writing committee that developed the scientific statement. “A lack of standards for measuring and calculating the ABI can lead to discrepancies that can significantly impact both prevention and treatment of cardiovascular disease,” he says. “The estimated prevalence of PAD may vary substantially according to the mode of ABI calculation.” Reducing Variation in ABI Technique Recent studies have revealed that techniques for performing the ABI vary from clinician to clinician. Several variables have been identified, including the position of patients during measurement, the sizes of the arm and leg cuffs, and the method of pulse detection over the brachial artery and at the ankles. Other variables include whether the arm and ankle pressures were measured bilaterally, which ankle pulses were used, and whether a single measure or replicate measures were obtained. Several recommendations have been endorsed by the AHA for measuring the ABI (Table 1). “These recommendations can serve as a guide to ensure that clinicians are measuring the ABI...
Improving Skills With Surgical Simulation

Improving Skills With Surgical Simulation

Requirements for surgical proficiency are generally based on an absolute number of procedures completed, but the pace at which people are trained or become proficient in a procedure tends to be highly individualistic. Skill levels progress at varying speeds. Setting a specific number of procedures for surgical training can lead to surgeons having variable skill levels. As a result, patient safety can be potentially impacted during and after training. Simulation technology has been thought of as a helpful tool to address both patient safety concerns and the varying speeds at which surgical trainees reach proficiency. A Simulator Is Born “When endoscopic sinus surgery was popularized in the 1990s, a number of complications were reported because of the proximity to the eyes and brain,” explains Marvin P. Fried, MD, FACS. “These complications included loss of eye muscle motion, vision, and brain fluid leakage. It was a new surgical technique on which surgeons needed training. Lockheed Martin then created a sinus surgery simulator with the purpose of providing a safe environment that looked and felt like human anatomy.” People who train on the simulator run an endoscope through the nose, and a corresponding image appears on a monitor. Users hold the handle of one of 24 instruments—ranging from needles to forceps—in their other hand. The simulator then measures how long procedures take and whether errors have been made. The technology simulates such things as bleeding when errors are made. Tasks are set to beginner, intermediate, and advanced levels. Putting Simulation to the Test Previous studies conducted by Dr. Fried and colleagues at Montefiore Medical Center indicated that the simulator looked and...

Should Resident Work Hours Be Capped?

Blogging at his site “Adventures in Emergency Medicine,” Dr. Sam Ko says resident work hours should be limited to 40 per week. Via Twitter, I warned him that I would rebut his assertion. Without any data or references except a tangential one, he bases his opinion on four premises: 1. “Residents will be happier and nicer to patients because they will be less stressed.” There is no proof that this is so. In fact, a recent paper in JAMA Surgery says about one-third of interns who work a maximum of 16 hours per day “demonstrated weekly symptoms of emotional exhaustion (28%) or depersonalization (28%), or reported that their personal-professional balance was either “very poor” or “not great” (32%). And “at the end of their intern year, 44% [of interns] said they did not believe that the work hours limits led to reduced fatigue.” This is not a very resounding confirmation of the theory that reducing work hours leads to happier or more rested residents. 2. “But we did it so you have to do it too.” Under this heading, Dr. Ko says, “We are busier than they were 20 to 30 years ago. Before, they probably got more sleep and had less patients in the hospital.” With the exceptions of more paperwork and the burden of the electronic medical record, I’m not so sure residents are busier today, but if they are, what’s making them busier is REDUCED WORK HOURS. This recent paper from JAMA Internal Medicine concluded the following: “Compared with a 2003-compliant model, two 2011 duty hour regulation-compliant models were associated with increased sleep duration during the on-call period...

Review: interventions to increase influenza vaccination among healthcare workers in hospitals

Abstract Annual influenza vaccination rates among hospital healthcare workers (HCW) are almost universally low despite recommendations from WHO and public health authorities in many countries. To assist in the development of successful vaccination programmes, we reviewed studies where interventions aimed to increase the uptake of influenza vaccination among hospital HCW. We searched PUBMED from 1990 up to December 2011 for publications with predetermined search strategies and of pre-defined criteria for inclusion or exclusion. We evaluated a large number of ‘intervention programmes’ each employing one or more ‘intervention components’ or strategies, such as easy access to vaccine or educational activities, with the goal to raise influenza vaccine uptake rates in hospital HCW during one influenza season. Included studies reported results of intervention programmes and compared the uptake with the season prior to the intervention (historical control) or to another intervention programme within the same season that started from the same set of baseline activities. Twenty-five studies performed in eight countries met our selection criteria and described 45 distinct intervention programmes. Most studies used their own facility as historical control and evaluated only one season. The following elements were used in intervention programmes that increased vaccine uptake: provision of free vaccine, easy access to the vaccine (e.g. through mobile carts or on-site vaccination), knowledge and behaviour modification through educational activities and/or reminders and/or incentives, management or organizational changes, such as the assignment of personnel dedicated to the intervention programme, long-term implementation of the strategy, requiring active declination and mandatory immunization policies. The number of these components applied appeared to be proportional to the increase in uptake. If influenza uptake in hospital...
Forgetting the Fast Food

Forgetting the Fast Food

The figure below shows the percentage of daily calories consumed from fast food among adults aged ≥20 years, by age group, in the United...
Avoidable Healthcare Costs

Avoidable Healthcare Costs

The IMS Institute for Healthcare Informatics estimates that $213 billion was spent on avoidable healthcare costs in the United States in...

Dumbing it Down: Where to Draw the Line?

Dumbing down medical information for patients can come in different forms. Some docs only provide the basics as to not overwhelm patients. Others may use a patronizing “you’ll be okay” tone that may be misleading. And recently a physician diagnosed a patient with “ghetto booty” instead of lumbar lordosis in an attempt to use slang to better explain a condition. So when is dumbing down technical verbiage to patients too dumb, dangerous – or offensive? The growing focus on health literacy is necessary, especially for those with a low literacy rate or for whom English is not their primary language.  The average American adult reads at a 7th to 8th grade level, so the American Medical Association, the NIH, and the U.S. Department of Health and Human Services encourage patient education materials to be written at a 4th to 6th grade reading level. But at what point does providing only basic information hinder patients from being advocates in their own care? Many healthcare professionals struggle with where to draw the line when it comes to effectively and clearly communicating information to their patients. Not every patient wants—or is capable—of handling the same amount of information. Healthcare professionals have to read the patient and situation to determine how much information to relay. Too much information may overwhelm patients or disclosing too many details of side effects may scare patients away from necessary treatment. At the same time, physicians are learning the hard way that automatically defaulting to the lowest common denominator may not always be the right answer or what’s in the patient’s best interests. Physician’s Weekly wants to know…Where...

Uncertain Diagnosis or CT Scan Radiation?

It is so nice to be right. To summarize what I wrote 2 and 3 years ago, here and here—based on my experience, patients and families will accept the theoretical risk of a future cancer if it means they’ll get an accurate diagnosis. A new study validates that opinion. MedPage Today reports that parents of 742 children who arrived at the emergency department with head injuries were surveyed by researchers from Toronto’s Hospital for Sick Children. The parents were queried before receiving any recommendation for CT scanning. Parents, almost half of whom had previously known that CT scanning might cause a cancer to develop in the future, were told of the radiation risks of CT scanning in detail. The authors found that, although the parents’ willingness to go ahead with the CT scan fell from 90% before the explanation of risk to 70% after they were briefed about radiation, at crunch time only 42 (6%) of them refused to let their child be scanned. And of the 42 who initially refused, 8 eventually went ahead with the scan after a physician recommended it. So to put it another way: Even after they were fully informed of the potential risk of CT scan radiation to their child (lifetime risk of cancer is about 1 in 10,000, according to the authors), nearly all parents opted for the scan. Also of note are the following: The median age of the children was 4; 12% of the children in the study had undergone at least one previous CT scan; 97% of the children were diagnosed with only concussions or mild head injuries. An...
ED Care of AF & Hospital Charges

ED Care of AF & Hospital Charges

The initial management of newly recognized atrial fibrillation and atrial flutter (AF) lasting over 48 hours is generally heart rate control along with anticoagulation to prevent future embolic events. Once rate control is achieved by emergency physicians, decisions on the timing of the rhythm control are often left to admission cardiologists. For cases in which AF duration is shorter than 48 hours, patients are often managed similarly. Recent studies, however, show that many of these patients can benefit from ED cardioversion (EDCV) to achieve normal sinus rhythm with discharge from the ED to home. Potential for Significant Savings In a study published in the Western Journal of Emergency Medicine, my colleagues and I examined 300 AF patients who came to the ED for care and were screened for timing of symptom onset. EDCV was considered if nursing or physician notes documented onset of AF symptoms within 48 hours of ED presentation in patients younger than 85. The median charges for EDCV patients were $5,460, compared with $23,202 for those admitted with no attempt at cardioversion. Median charges for patients whose final ED rhythm was normal were $5,641; for those remaining in AF, median charges were $30,299. A surprising finding from our study was that the resource savings produced by simply attempting EDCV, regardless of the results, were also significant. Admitted patients remaining in AF following cardioversion attempts still had hospital charges that were $8,628 lower than those admitted with no EDCV attempt. Efficient & Effective The longer a heart remains in AF, the more the atrium becomes conditioned to accept this rhythm. The sooner after the onset of AF...
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