Are Resident Wellness Programs Enough When Death, Injury & Violence Are the Stressors?

Urgent MattersSeptember 25, 2017September 25, 2017Leave a comment

James Spearman

September 25, 2017

The EMS team bursts through the door while the patient moans in agony, raising the tension in the room. The medical team quickly moves the injured body from the stretcher to the bed. The junior resident at the head of the bed calls “airway intact” while trying to concentrate on breath sounds. The senior at the foot of the bed attempts focuses on the EMS report while he impatiently waits for the vitals to appear on the monitor. Another resident tears through the patient’s clothes to begin the FAST, trying to concentrate on the patient and the screen at the same time. Though not guaranteed, one of the five people mentioned is statistically likely to be suffering from Post-Traumatic Stress Disorder (PTSD). How can you tell? What are the signs? Constricted affect: check; hypervigilance: check; irritability: check. But is there impairment? The critical factor in many psychiatric diagnoses — distress or reduced ability to function. There is no easy answer.

PTSD is a well-established risk for Emergency Medicine (EM) providers from EMS to the trauma bay ¹. In-hospital EM providers experience PTSD at more than double the rate of the general population, somewhere between 15 - 20% ². Rates in first responders have been shown be as high as 40%. Evaluation of the DSM-5 criteria for PTSD begins with “exposure to actual or threatened death, serious injury, or sexual violence,” including “experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (eg, ﬁrst responders collecting human remains; police officers repeatedly exposed to details of child abuse),” which clearly includes EM professionals ³. The diagnosis in this population is confounded by the stigma of perceived weakness, and the volume of trauma seen, i.e. which one was the precipitating cause.

EM residents experience PTSD at similar rates as the EM physician population ⁴. Changes to duty hours and time off policies have improved resident satisfaction while reducing stress and burn out ⁵. The focus on resident wellness includes training strategies for sleep, exercise, nutrition, health, work-life balance, mindfulness and positivity ⁶. These changes are critical to the long-term well-being of the profession; they may not be the only measures necessary.

In a paper in press in Annals of Emergency Medicine, Vanyo et al makes a comprehensive evaluation of PTSD in Emergency Medicine residents ⁷. They note overall improvement in resident well-being but found “no specific effort has yet been made to identify, prevent, and treat the emotional distress that results directly from repeatedly witnessing trauma among emergency medicine resident physicians.” In addition to the challenges of diagnosis, there is little evidence for effective methods of prevention.

When diagnostic criteria are clearly met for PTSD, there are treatment options supported by randomized controlled trials. Several categories of treatment include trauma-based cognitive behavioral therapy, debrieﬁng (critical incidence stress debrieﬁng), cognitive behavioral stress management, mindfulness-based stress reduction, autogenic training, and relaxation response training. There is a notable similarity between these methods and some generalized wellness practices. However, the authors caution against grouping wellness and PTSD together. Of these methods, trauma-based cognitive behavioral therapy reduced rates of PTSD to 9% compared to 42% with general counseling ⁸, thus highlighting the need for specialized treatment. Interestingly, the authors noted that mindfulness, which is increasingly a component of wellness programs, has been shown to be particularly effective in studies of PTSD in the military, who are similarly stoic like in-hospital EM providers.

Exposure to trauma in the Emergency Department provides the textbook environment for the development of PTSD. Most in-hospital EM physicians begin experiencing trauma on a regular basis during residency, which is already a time of heightened stress. Residency wellness programs are effective at reducing the negative impacts of generalized stress, but should improve mechanisms for the detection and treatment of PTSD before distress becomes impairment. Additional research is needed on prevention, especially in the resident population.

References

Lum G, Goldberg RM, Mallon WK, Lew B, Margulies J. A survey of wellness issues in emergency medicine (Part 2). Ann Emerg Med 1995;25:242-8.
Luftman K, Aydelotte J, Rix K, et al. PTSD in those who care for the injured. Injury 2017;48:293-6.
Pai A, Suris AM, North CS. Posttraumatic Stress Disorder in the DSM-5: Controversy, Change, and Conceptual Considerations. Behav Sci (Basel) 2017;7.
Mills LD, Mills TJ. Symptoms of post-traumatic stress disorder among emergency medicine residents. J Emerg Med 2005;28:1-4.
Choi D, Cedfeldt A, Flores C, Irish K, Brunett P, Girard D. Resident wellness: institutional trends over 10 years since 2003. Adv Med Educ Pract 2017;8:513-23.
Ross S, Liu EL, Rose C, Chou A, Battaglioli N. Strategies to Enhance Wellness in Emergency Medicine Residency Training Programs. Ann Emerg Med 2017.
Vanyo L, Sorge R, Chen A, Lakoff D. Posttraumatic Stress Disorder in Emergency Medicine Residents. Ann Emerg Med 2017.
Ponniah K, Hollon SD. Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review. Depress Anxiety 2009;26:1086-109.

James Spearman is a fourth year medical student at the Medical University of South Carolina.

Just Breathe: Supplemental Oxygen Provides No Benefit in Acute Myocardial Infarction

Urgent MattersSeptember 18, 2017Leave a comment

Greg Jasani

September 18, 2017

Acute myocardial infarction (AMI) occurs when a mismatch between oxygen supply and demand in the myocardium of the heart leads to ischemia and ultimately cell death. Clinical guidelines currently support the routine use of supplemental oxygen in patients experiencing an AMI.[1] The rationale for providing supplemental oxygen is to increase the oxygen delivered to the ischemic myocardium to limit the size of the infarct and reduce complications. Recently, however, the benefit of supplemental oxygen in these patients is being questioned. A 2016 Cochrane Review article concluded: “there is no evidence from randomized controlled clinical trials to support the routine use of inhaled oxygen in people with AMI...randomized controlled trials are urgently required to inform guidelines in order to give definitive recommendations about the routine use of oxygen in AMI”.[2]

Yet recently, an article published in the New England Journal of Medicine filled that need. The Determination of the Role of Oxygen in Suspected Acute Myocardial Infarction (DETO2X-AMI) trial was a randomized, controlled clinical trial that compared supplemental oxygen to room air in patients with suspected AMI.[3] The trial enrolled patients 30 years of age or older, had a suspected MI (defined as a chief complaint of either chest pain or shortness of breath), with an oxygen saturation of 90% or greater, and with EKG changes suggestive of ischemia or elevated troponin at presentation. Patients were then randomized to either receive 6 L/min of O2 by facemask or to receive no supplemental oxygen therapy. The primary endpoint was all cause mortality at 1 year. Additionally, the authors measured all cause mortality at 1 month, re-hospitalization with MI, re-hospitalization with heart failure, and cardiac-related mortality.

Over 2 years, 6,629 patients were enrolled through 35 participating hospitals in Sweden. Of these, 5010 were ultimately found to have an MI. A total of 3311 were randomized to the supplemental oxygen group and 3318 to the ambient-air group. All cause mortality at 1 year for patients who received supplemental oxygen was 5.0% compared to 5.1% for patients in the ambient-air group (p = 0.80). The authors also found no significant differences between the two groups with respect to all cause mortality at 1 month, re-hospitalization with either an AMI or heart failure, or cardiac mortality. Additionally, troponin levels did not significantly differ between the two study groups.

The DETO2X-AMI study showed that administering supplemental oxygen to non-hypoxic patients with suspected AMIs did not improve mortality at either one month or one year. Additionally, administration of oxygen did not appear to affect infarct size as both groups had similar troponin levels. To date, the DETO2X-AMI trial is the largest randomized controlled clinical that evaluates the use of supplemental oxygen in AMI. Its findings cast doubt on the benefit of routine oxygen therapy in these patients. With this evidence, clinicians should consider supplemental oxygen ineffective in AMI patients without hypoxia, and ultimately it may be removed from clinical guidelines.

References:

[1] Roffi M, Patrono C, Collet JP, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016;37:267-315

[2] Cabello JB, Burls A, Emparanza JI, Bayliss SE, Quinn T. Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev 2016;12:CD007160-CD007160

[3] Hofmann R, James S, Jemberg T, Lindahl B, Erlinge D, Witt N, et al. Oxygen Therapy in Suspected Myocardial Infarction. N Eng J Med. Published online August 28, 2017

Greg Jasani is a fourth year medical student at the GW School of Medicine & Health Sciences

Linking Maternal Comorbidities to Emergency Department Use in a National Sample of Commercially Insured Pregnant Women

Urgent MattersSeptember 13, 2017September 13, 2017Leave a comment

Rose Kleiman

September 13, 2017

Despite recent efforts to push engagement with primary care and the health system, pregnant women still find themselves seeking emergency department (ED) care[i].

A recent study published in Academic Emergency Medicine sought to better understand the association between maternal comorbidities and ED use. The research team focused on the following comorbidities common in pregnancy: hypertension (pre-eclampsia and eclampsia), diabetes, gestational diabetes, obesity and asthma. The study limited their focus to women between the ages of 18 and 44 who were commercially insured during the pregnancy and up to 6 months afterward. Their analyses control for a known increased use of the ED among rural patients and tries to take into account patient demographics (such as race, ethnicity, income) by controlling for variation in use of the ED by zip code.

The study found that 20% of the women had one or more ED visit and that among those who had used the ED, almost 30 percent (20%) had two or more visits, and over 10 percent (11%) had three or more visits. The mean number of ED visits among pregnant women who received emergency care was 1.52 visits. Even though many sought ED care, only 0.4% of the visits resulted in a hospital admission.

The research team also found that those who sought out any ED care were significantly more likely to have one or more comorbid condition (30 percent vs. 21 percent). All of the comorbid conditions that the group identified as common pregnancy related comorbidities were associated with increased odds of seeking emergency care. Asthma in particular increased the likelihood of a woman receiving emergency care by 2.5 times, which is consistent with other studies of conditions that drive ED use. Table 1 (below) summarizes which patient characteristics lead to increased likelihood of an ED visit.

Table 1. Adjusted Parameter Estimates for Any Prenatal ED Visit

One limitation of this study is that it focused solely on commercially-insured women. It would be interesting to look at ED use among publically-insured women, who may not have the same routine prenatal care that commercially insured women do. Some studies have shown that almost 50% of low-income pregnant women receive emergency care at least once during their pregnancy[ii]. Thus it will be important to look at use of the ED in populations of women who are not commercially insured and try to further study if there are predictors that can be used to help identify potential pregnant frequent ED users.

This study shows that insurance coverage alone does not sufficiently meet the care needs of pregnant women, specifically those with comorbid conditions. A lot of work in healthcare delivery and policy reform has been focused on alternative models of care to keep people out of the ED and increase access to alternative sites. Pregnant women are a population who might benefit from models of care that focus on extended office hours and more involved case management.

[i] Cunningham, S. D., Magriples, U., Thomas, J. L., Kozhimannil, K. B., Herrera, C., Barrette, E., ... & Ickovics, J. R. (2017). Association between Maternal Comorbidities and Emergency Department Use among a National Sample of Commercially‐insured Pregnant Women. Academic Emergency Medicine.

[ii] Magriples U, Kershaw TS, Rising SS, Massey Z, Ickovics JR. Prenatal health care beyond the obstetrics service: utilization and predictors of unscheduled care. Am J Obstet Gynecol 2008;

Rose Kleiman is a medical student at the GW School of Medicine & Health Sciences

ED Crowding and Changes for Improvement

Urgent MattersSeptember 6, 2017September 6, 2017Leave a comment

Sonya Chistov

September 6, 2017

Emergency departments (ED) across the country are combating the problem of “crowding”. A combination of sources are commonly cited as the reason for crowding including the increase in ED visits in the past twenty years, the decrease in EDs across the country, and lack of space or staff in EDs. Despite these relevant issues, a dominant cause of crowding in the ED is admitted patient boarding [1].

When all inpatient beds are occupied, the ED is responsible for boarding patients within their rooms and hallway spots. This entire process influences ED metrics such as average wait times, time to triage, time to decision/admission, and the number of patients who leave without being seen. Aside from ED operational logistics, the quality of care for boarded admitted patients is coming into question. The Joint Commission reported crowding contributing to 31% of sentinel events in the ED. Errors that lead to sentinel events can occur as a result of hurried treatment, decisions based on limited information or poor transfer of information, delayed order completion, and limited reevaluation of treatment plans or temporary diagnosis. [1] In addition, ED boarding is associated with longer lengths of stay within the inpatient units, as well as increased patient mortality. [2] With all of this mounting information about the hazards of boarding, what barriers prevent patients from moving from the ED to inpatient units when available?

Beyond the metrics of having available beds, turnaround time for cleaning, and transport from the ED to inpatient floors, there needs to be an examination of the, often intangible, hospital culture in our current healthcare system. Hospital culture is defined as a set of assumptions formed by a hospital group to resolve internal and external pressures, taught to new members as a preferred method to think and deal with these pressures. Hospital culture is layered and dynamic, with surface traits such as dress code to core staff mentality, which dictates performance and ultimately patient outcome. [3] McClelland et al. developed The Hospital Culture of Transitions (H-CulT) survey to assess organizational culture related to intra-hospital transitions in care, specifically with patient movement. The survey measures seven subscales in the culture of transitions: Hospital Leadership, Unit Leadership, My Unit’s Culture, Other Units’ Culture, Busy Workload, Priority of Patient Care and Use of Data. The questions from each subset gauged the perceptions of staff members towards things like policies and procedures, teamwork in transition, staff’s perception of timeliness, and even barriers to effective transitions. Respondents were also asked to give an overall grade (A-F) on patient transition within their hospital. Finding discrepancies in a specific subset can indicate the type of intervention needed within the hospital, to promote more cohesive and timely transition of patients from unit to unit. For instance, if respondents suggest that there is a delay in transition because of specific staff avoidance in accepting new patients, a unit profile can be developed and a new system of transfer can be implemented. Each hospital faces different barriers, but ultimately this study found the H-CulT survey to be effective and practical for assessing hospital culture in relation to patient flow and provides potential guidelines to mediate these issues.

If ED crowding can be directly correlated with a hospital’s culture, what can we do to reconcile this culture and ultimately provide a safe and patient-focused plan to mediate this problem? In 2001, Peter Viccellio, Vice Chair of The Department of Emergency Medicine at Stony Brook University Hospital, initiated a “full-capacity” protocol. He disagreed with the existing protocol of admitted, stable patients to board in the ED until an inpatient bed became available. Instead, he suggested that if the entire hospital has reached full capacity, any patient that would be placed in the ED hallway to wait, could and should be placed in the hallways of the inpatient floors. Viccelio and his team conducted a longitudinal study within their hospital to address concerns for patient safety as a result of their newly established procedure. Their study concluded that transfer of admitted, hallway placed patients to inpatient floor hallway did not increase patient mortality or emergency ICU upgrades. [4] In addition, studies suggest that patients would prefer to be sent to inpatient hallway beds than stay in the ED hallway, which can increase patient satisfaction hospital wide. [5]

ED crowding is a complex issue that contains many variables, but with improved methods to measure what was once deemed indefinable, action should be taken when available. With changes in hospital culture or implementation of updated protocols, hospitals can tackle the issue of ED crowding to provide more patient-focused and safe care.

[1]Moskop JC, Sklar DP, Geiderman JM, Schears RM, Bookman KJ. Emergency department crowding, part 1—concept, causes, and moral consequences. Annals of emergency medicine. 2009 May 31;53(5):605-11.

[2]Singer AJ, Thode Jr HC, Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Academic Emergency Medicine. 2011 Dec 1;18(12):1324-9.

[3]McClelland M, Bena J, Albert NM, Pines JM. Psychometric Evaluation of the Hospital Culture of Transitions Survey. The Joint Commission Journal on Quality and Patient Safety. 2017 Jul 19.

[4]Viccellio A, Santora C, Singer AJ, Thode HC, Henry MC. The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience. Annals of emergency medicine. 2009 Oct 31;54(4):487-91.

[5] Viccellio P, Zito JA, Sayage V, Chohan J, Garra G, Santora C, Singer AJ. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. The Journal of emergency medicine. 2013 Dec 31;45(6):942-6..

Sonya Chistov is an ED Technician at The George Washington University Hospital

Month: September 2017