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ACS 2014: Checklists for Surgical Patient Handoffs

The Particulars: Previous research has found that implementing a shift change protocol called PACT—which stands for Priority, Admissions, Changes, and Task Review—enables surgical residents to complete more tasks and learn more about patients on morning rounds. Use of a checklist may enhance the PACT protocol. Data Breakdown: For a study, researchers used a focus group to design a four-item checklist that was to be used with the PACT protocol. The checklist asked physicians to designate a leader, pre-mark their handoff list, move to a quiet place, and set communication devices to vibrate. Handoffs using PACT with the checklist were compared with those using PACT alone. The following was observed: Parameter PACT Alone PACT With Checklist Average handoff time 22 minutes 15 minutes Average number of interruptions 4 2 Average errors per shift 0.03 0.00 Percentage of incomplete tasks per shift 27% 28% Take Home Pearl: Use of a checklist in addition to PACT protocols appears to improve communication and reduce handoff times, interruptions, and errors during surgical patient...

ACS 2014: Predicting Joint Replacement Outcomes

The Particulars: In most cases, eligibility for hip and knee replacement surgery has been based largely upon the patient’s biological age. Recent research suggests, however, that a patient’s level of frailty may be a reliable independent risk factor for adverse health outcomes. Data Breakdown: Researchers in Detroit created and implemented a simplified frailty index to stratify risks for mortality and morbidity in more than 40,000 hip and knee replacement patients. Based on 11 data points collected by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, the index included items that can easily be obtained by taking a simple medical history. Patients with high frailty scores had significantly higher mortality and serious postoperative complication rates when compared with those with low frailty scores. The frailty index was a more reliable predictor of mortality and serious complications than patient age. Take Home Pearl: A simple frailty index that is mapped to the ACS NSQIP database appears to be more reliable than patient age in predicting adverse outcomes among patients considering joint...

ACS 2014: Smartphones for Wound Assessment

The Particulars: Anecdotal experience suggests that using smartphones to remotely monitor postoperative incisional wounds via digital photos may improve outcomes and promote patient-centered care. However, few studies have explored the impact of current smartphone capabilities and patient willingness to adopt the technology for this purpose. Data Breakdown: A survey of elderly patients undergoing vascular surgery found that nearly 90% owned a smartphone or knew someone who could help them take and send photos with such a device. More than 90% reported that they would be willing to take photos of their wounds with a smartphone. Every survey respondent said they would be willing to answer questions regarding their health status via a smartphone. Potential barriers to adopting a smartphone wound protocol that were identified included logistics related to taking photos, health-related questions, and coordination with caretakers. Take Home Pearls: Older surgical patients appear to be willing to adopt a smartphone-based postoperative wound monitoring program. Caregiver involvement appears to a crucial element in the success of this...

ACS 2014: Perforated Appendicitis in Pediatric Patients

The Particulars: Researchers have hypothesized that pediatric appendicitis perforation rates may be related to age, general surgical care availability, and distance from pediatric surgical care. However, this hypothesis has yet to be confirmed in a study. Data Breakdown: Among nearly 7,000 pediatric surgical patients included in a study, about one-quarter had an appendicitis perforation. Children ages 0 to 12 were at higher odds of appendiceal perforation when compared with those aged 12 to 18. Children who were transferred to another facility or who resided in counties with less than three general surgeons per 100,000 population were most likely to have a perforated appendix. Take Home Pearl: Younger age, requiring a transfer to another facility, and residing in areas with fewer general surgeons appear to be associated with higher odds of appendiceal perforation among pediatric...

ACS 2014: Assessing Online Sources on Prostate Cancer Screening

The Particulars: Data indicate that patients are increasingly using the internet to obtain health-related information. In 2012, the United States Preventive Services Task Force (USPSTF) released recommendations against routine prostate cancer screening. The online consensus regarding prostate cancer screening—including accuracy, use of reliable sources, and support of the USPSTF recommendations—is not well known. Data Breakdown: For a study, researchers analyzed the first page of results after performing a search for “prostate cancer screening” using three top search engines. Among 10 internet sites from the U.S. government, one from Britain, three from academic institutions, four from health organizations, and 11 from commercial media sites, the study team found that 96.5% of all websites targeted the public. One presented information that was biased and could easily be misinterpreted. Only about half of the sites included references and roughly two-thirds advocated informed decisions after discussing screening risks and benefits with physicians. Five sites offered no conclusions and only five recommended against prostate cancer screening. Take Home Pearl: Most websites that focus their content on prostate cancer screening appear to contradict the USPSTF recommendations against routine prostate cancer...

ACEP 14: Triage-Leveling & ED Crowding

The Particulars: Triage classification systems commonly assign five levels to patients. In these systems, level 1 and 2 patients are often given priority for ED bed assignment and level 4 and 5 patients are seen in designated locations. The throughput and utilization characteristics of level 3 patients remain unclear in comparison to patients with other triage levels. Data Breakdown: A data analysis of more than 250 million ED visits was conducted, among which more than 100 million were for level 3 patients. Day of the week, time of arrival, and average pain scale level did not vary significantly between any triage level groups. However, level 3 patients had the longest wait times. Average length of visit times and visit proportions requiring tests or procedures were similar for level 1 through 3 patients and were significantly higher for level 4 and 5 patients. Take Home Pearls: Triage level 3 patients appear to be more similar to level 1 and 2 patients than to level 4 and 5 patients with regard to length of stay and number of tests and procedures ordered. However, level 3 patients appear to have the longest wait...

ACEP 14: Outcomes With High-Risk Care Plans

The Particulars: High-risk care plans are increasingly being used to assist in the management of patients who are big users of ED resources. However, little is known about the outcomes obtained with these plans in a real-world setting. Data Breakdown: In a study, researchers analyzed data on high utilizers of ED services who had been seen for 6 months prior to and 6 months after the implementation of a high-risk care plan. When comparing pre- versus post-implementation, the study group observed decreases in the number of x-rays, CT scans, morphine equivalents, ED visits, admissions, and observation stays. Radiation exposure decreased significantly as a result of reductions  in the number of x-rays and CT scans . Take Home Pearl: High-risk care plans for high utilizers of ED services appear to significantly reduce radiation exposure and achieve other important measures of quality...

ACEP 14: Reconsidering Physicians at Triage

The Particulars: Many EDs now include a physician at triage in an effort to improve flow and expedite care. Reports on the outcomes of making this change have been mixed, and its impact on common throughput metrics is not well known. Data Breakdown: Investigators conducted a before-and-after study in which they moved the triage physician to the main ED and reassigned staff to create teams. These teams included one mid-level physician or physician assistant, an attending physician, at least one nurse, and a technician. Patients were triaged by a nurse, assigned to a team, and pulled into the main ED by that team rather than by the charge nurse.  When compared with the month preceding the intervention and the same 3 months of the previous year, the research found that the following all decreased during the 3 months following the change: Time to provider. Time to attending. Time to disposition. Length of stay. The number of patients who left without being seen. Take Home Pearl: Moving an attending physician from triage to a team in the main ED appears to improve patient throughput times and achieve other important...

ACEP 14: Alcohol Use & Repeat ED Visits

The Particulars: Research indicates that patients with recurrent ED visits for trauma represent an important target for injury prevention efforts. If has not been well defined whether a history of alcohol use at initial trauma-related visits predicts risk of recurrent injuries. Data Breakdown: A chart review of patients with ED visits for trauma who were screened for alcohol risk found that high-risk drinkers had a greater likelihood of a return visit for trauma (odds ratio, 2.45) than low-risk drinkers. High-risk drinkers also had a greater number of subsequent ED visits, were more likely to return to the ED, and had more return visits to the ED when compared with low-risk drinkers. The authors also found that high-risk drinkers were more likely to have a subsequent ED visit requiring hospital admission for management of a traumatic injury within 24 months. Take Home Pearls: Trauma patients with high-risk drinking behaviors appear to be more likely to return to the ED within 24 months of the initial visit. They also have a greater likelihood of subsequent trauma-related hospital admissions within 2 years and have more trauma-related ED visits when compared with patients with low-risk drinking...

ACEP 14: A Look at ED Care and ED-Directed Healthcare Costs

The Particulars: Data are lacking on the potential magnitude of cost savings from interventions directed at ED encounters. An understanding of ED care and ED-directed healthcare costs by type of visit and the proportion of national health expenditures made up by these costs may help shed light in this area. Data Breakdown: For a study, researchers analyzed national data to determine the average per visit payments and charges for ED outpatient and inpatient encounters by visit type. Among all encounters involving ED-directed healthcare, the greatest per visit expenditures were attributable to hospital admissions from the ED. Non-urgent outpatient ED visits generated the lowest per visit expenditures. ED-directed healthcare accounted for 11.2% of national health expenditures, including 7.0% from ED admissions and 4.2% from outpatient ED visits. Take Home Pearl: Efforts to reduce costs associated with ED care and ED-directed healthcare may be most effective if they target the emergency physician’s role as a gatekeeper to hospital...
Ebola, Leadership, and Responsibility

Ebola, Leadership, and Responsibility

I am a surgeon. I am not an Epidemiologist nor an Infectious Disease specialist. Anything I say on this subject should be regarded as the musings of an educated layman. That said, I have been profoundly disappointed in the response of my profession to the current Ebola scare in this country. I don’t use the word crisis because it is not a crisis in the United States. The crisis is in West Africa. Nevertheless, the media have done little to calm fears of rampant spread of the disease to America. The response of our professional organizations and public health institutions has been scientifically correct and yet has been an abject failure in the eyes of the public. The guidelines coming out of the CDC and the Public Health Service seem fragmented, incoherent, and sometimes contradictory. Measures, which in the public mind seem reasonable such as flight bans and quarantines, are dismissed with an attitude of superiority that borders on arrogance. I know the reasons that such measures were not recommended, but those reasons were not communicated in such a way that the lay person could understand and support. Instead, the response of the experts sounds dismissive and political rather than reasonable and scientific. Leadership involves more than issuing the correct orders and directives. It also means effective communication of the mission and goals of the organization. In this case, there has been a failure of leadership from the top. “The experts have done little to alter the perception that they are either political hacks or arrogant academics…”   Some of the irrationality about this disease can be blamed on...

Social Media Tips for Doctors

Recently, I was asked for personal advice on using Twitter. There are many articles out there that say we (physicians) don’t know how to properly use social media. Social media can be a very powerful tool in medicine. It can not only help us get medical information out there to our patients, but it can also help us connect with people, colleagues, and organizations to give us more visibility—whether for career advancement, media contacts, or just to get our voices heard. Social Media Basics: These are some of the tips I have come up with for doctors who want to take advantage of the many opportunities social media can offer: 1. Never communicate to patients through social media outlets. It is a set up for disaster and HIPAA violations. 2. Social media can be used for educating patients. Patients can follow you on these pages to get information about your practice and whatever medical information you wish to share. Twitter… 3.  Twitter is useful for growing your professional connections. It can be leveraged so you get known and also connect with other doctors, healthcare information technology people, media, etc. Patients can follow you on Twitter, but it generally is not a useful method of providing patient information because tweets are limited to 140 characters. 4. Choose your followers carefully. Block those who spam or troll you (“trolls” are people who negatively post with the deliberate intent of provoking a reaction). Many people will try to sell you things. Monitor your account because it is not uncommon for it to be hacked. 5. Grow your network. Have a group that...
New Ebola Guidelines for Emergency Departments

New Ebola Guidelines for Emergency Departments

The American College of Emergency Physicians (ACEP) has been working with the CDC and the Emergency Nurses Association to establish procedures to help emergency personnel evaluate and manage emergency patients suspected of possible Ebola infection.  The CDC published the new guidelines for emergency departments during ACEP’s annual meeting where experts from across the country are meeting to discuss key issues, including Ebola. The new guidelines, an Ebola management algorithm, can be found and printed here. The guidelines were evaluated and approved by a panel of experts—consisting of emergency physicians and emergency nurses with expertise in infectious disease and disaster preparedness—appointed by ACEP’s president. “It’s critical to protect the emergency medical staff who are on the front lines of caring for patients who may have Ebola,”  said Alex Rosenau, MD, FACEP, immediate past president of ACEP.  “They are the ones most at risk for contamination, because they come in direct contact with the patient, as demonstrated by the infections of the nurses in Dallas and the recent case of the emergency physician in New York.   On behalf of our 34,000 members, we are so grateful for the recovery of the nurses and we are optimistic that Dr. Spencer will recover as well. ” The CDC guidelines include advice for: ♦ Assessing patients, including those for whom travel histories are unavailable (for example, when patient s are unconscious). ♦ Putting on (donning) and removing (doffing) of personal protective equipment (PPE). ♦ Managing and isolating patients who may have Ebola. ♦ Informing hospital personnel and other authorities about possible infection. ♦ Providing direct observation of health care workers during the donning and...
Treating Anemia in Heart Disease Patients

Treating Anemia in Heart Disease Patients

Studies indicate that anemia occurs in about one-third of patients with congestive heart failure and up to 20% of those with coronary heart disease (CHD). The condition has been linked to an increased risk for hospitalizations, decreases in exercise capacity, a poorer quality of life, and higher mortality. The risks and benefits of treating anemia in patients with heart disease are important to understand. Providing Guidance In the Annals of Internal Medicine, the American College of Physicians (ACP) published guidelines that presented the current evidence and provided clinical recommendations on the treatment of anemia and iron deficiency in adults with heart disease. The guideline was based on a review of the literature on anemia and iron deficiency published from 1947 to 2013. The first recommendation made in the guideline was to use a restrictive red blood cell transfusion strategy (trigger hemoglobin threshold of 7 to 8 g/dL, compared with a higher hemoglobin level) in hospitalized patients with CHD. “When compared with a restrictive transfusion strategy, there is low-quality evidence that showed no benefit of using a liberal transfusion strategy in which the trigger threshold for hemoglobin levels was greater than 10 g/dL,” says Amir Qaseem, MD, PhD, who was lead author of the ACP guideline. “This strategy will likely be a slight shift from the aggressive approaches clinicians have used in the past.” ACP also recommends against the use of erythropoiesis-stimulating agents (ESAs) in patients with mild-to-moderate anemia and congestive heart failure or CHD. “This is a strong recommendation that was made on moderate-quality evidence,” says Dr. Qaseem. “We found that the harms of treating patients with mild-to-moderate anemia...
Guidance for PCI Without On-Site Surgical Backup

Guidance for PCI Without On-Site Surgical Backup

In 2007, the Society for Cardiovascular Angiography and Interventions (SCAI) published an expert consensus document on the current status and future direction of PCI without on-site surgical backup. The document reviewed the existing literature and examined recommendations for performing PCI in this setting from several existing programs and other sources, thereby defining best practices for facilities and operators. “Since that time, new studies, meta-analyses, and randomized trials have been published in which PCI with and without on-site surgery has been compared,” says Gregory J. Dehmer, MD, FACC, FACP, FSCAI. “In addition, professional organizations have published appropriate use criteria for coronary revascularization and other documents affecting the practice of PCI.” According to Dr. Dehmer, several noteworthy changes occurred in PCI guidelines that were released in 2011. “Elective PCI was upgraded to Class IIb, and primary PCI was upgraded to Class IIa at facilities without on-site surgery,” he says. In addition to the PCI guidelines, expert consensus documents and competency documents related to PCI plus additional research have provided more information on ways to optimize the structure and operation of PCI programs without on-site surgery. Consolidating Recommendations In 2014, SCAI—in collaboration with the American College of Cardiology and the American Heart Association—released a new expert consensus document on PCI at sites without on-site surgical backup. This document consolidates the myriad of recommendations that have been released in different forms since the 2007 document. “The recommendations are designed to improve safety while maintaining access to quality care,” says Dr. Dehmer, who was lead author of both the 2007 and 2014 consensus documents. As cited in the new document, 11 original studies and...
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...
Progress Seen in Managing Blacks With HIV

Progress Seen in Managing Blacks With HIV

Research has shown that the percentages of blacks who are linked to and retained in HIV care, taking antiretroviral therapy (ART), and achieving viral suppression are lower than those of other racial and ethnic groups. According to recent estimates, blacks account for 44% of the total number of people in the United States living with HIV but represent just 12% of the U.S. population. The National HIV/AIDS Strategy was developed in an effort to reduce the number of new HIV infections, increase access to care, improve health outcomes for those with HIV, and reduce HIV-related health disparities. “To achieve these goals, blacks with HIV need high levels of care and viral suppression,” says Y. Omar Whiteside, PhD. Achieving these goals calls for 85% of blacks with diagnosed HIV to be linked to care, 80% to be retained in care, and the proportion with undetectable viral loads to increase by 20% by 2015. A Large Analysis In an issue of the Morbidity & Mortality Weekly Report, Dr. Whiteside and colleagues conducted a study to provide clinicians with proxy measures to determine where the U.S. stands in achieving the goals outlined in the National HIV/AIDS Strategy. The analysis included 19 jurisdictions with complete reporting of all levels of CD4 and viral load test results. These jurisdictions represented 44% of all blacks with HIV living in the U.S. in 2010. The study found that about 75% of blacks diagnosed with HIV were linked to care, but less than half received regular care or were prescribed ART, and only about one-third had achieved viral suppression. “One of the most important findings was that...
The Impact of Test Fee Knowledge

The Impact of Test Fee Knowledge

Hospital patients and providers are often unaware of the fees that come with most medical services. “The healthcare system is oftentimes not transparent in actual costs for these services,” says Leonard S. Feldman, MD. Failure to have a sense of costs can increase waste in medicine by ordering expensive and often unnecessary tests and/or medications. This can increase healthcare costs, side effects, and false-positive results, and lead to additional unnecessary testing. Are you prone to overuse? Analyzing Cost Transparency In JAMA Internal Medicine, Dr. Feldman and colleagues had a study published that sought to determine if allowing physicians who order radiologic and laboratory diagnostic tests to see the costs of these diagnostics would prompt them to only order tests they felt would bring high-quality care to patients. The authors randomly assigned 61 diagnostic laboratory tests to an “active” arm, in which fees were displayed, or to a control arm, in which fees were not displayed. During a 6-month baseline period, no fee data were displayed. At 1 year later, fee data were displayed, based on the Medicare allowable fee, for active tests only during a 6-month intervention period. “This approach helped us identify any secular trends as well as any changes in test ordering rates that were isolated to the active arm,” explains Dr. Feldman. Important Findings Displaying fees in the active arm led to a reduction in the rates of test ordering from 3.72 tests per patient per day in the baseline period to 3.40 tests per patient per day in the intervention period. “This was nearly a 9% difference,” Dr. Feldman says. “At the same time, the...
An Update on Pulmonary Rehabilitation

An Update on Pulmonary Rehabilitation

In 2006, the American Thoracic Society (ATS) and European Respiratory Society (ERS) released a joint statement on pulmonary rehabilitation, a comprehensive, interdisciplinary intervention that had been recognized as a core component in managing patients with chronic respiratory disease. Since that time, there has been considerable growth in the science and application of pulmonary rehabilitation. In the American Journal of Respiratory and Critical Care Medicine, the ATS and ERS updated the 2006 statement, addressing newly gained knowledge surrounding the efficacy and scope of pulmonary rehabilitation. A New Definition A key component of the new statement is an updated definition of pulmonary rehabilitation endorsed by the ATS and ERS based on current insights. It states that “pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, including (but not limited to) exercise training, education, and behavior changes.” The definition notes that pulmonary rehabilitation is designed to improve the physical and emotional condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors. Bundling Approaches Whereas components of pulmonary rehabilitation can be provided as good medical care, pulmonary rehabilitation combines these interventions. The major components of pulmonary rehabilitation include exercise training and behavioral interventions. Dr. ZuWallack says that, when used as a bundle in pulmonary rehabilitation, these interventions are tailored to the needs and goals of the individual patient. To meet these goals, pulmonary rehabilitation is provided by an experienced and dedicated interdisciplinary team, including a combination of physicians, nurses, nurse practitioners, respiratory therapists, physical therapists, occupational therapists, psychologists, behaviorists, exercise physiologists, nutritionists, and social workers. “Pulmonary rehabilitation programs will vary...
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