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Month: January 2018

Published on Leave a comment on Natural Disasters and Hospital Care

Leah Steckler, MD

January 15th, 2018

As we enter the New Year, it is hard to forget the many lessons of 2017, a year that will likely be remembered for several reasons, among them the seemingly never-ending natural disasters. This past September, Hurricane Maria was the most powerful to hit Puerto Rico in almost 100 years (1).

Hearing stories from providers, like that from Dr. Zorrilla’s account published in November in the New England Journal of Medicine (NEJM) gives us a glimpse into what it might be like to practice in a far less than ideal environment (1). Importantly, Dr. Zorilla, an obstetrician-gynecologist, notes that neither she nor her staff had training in disaster management, and that it would have been difficult to predict and prepare for the level of devastation that Puerto Rico experienced. When a hospital is involved in a natural disaster, it is still vital to provide good quality patient care with few interruptions despite limited resources.

Accessing clean water was one of the challenges described in the NEJM article. According to the World Health Organization, 15% of patients worldwide develop an infection during a hospital stay, and this occurs with increased frequency in low-income countries with limited access to clean water (2).

Keeping track of any acquired illnesses, and accounting for chronic problems, also proves to be difficult without access to electronic medical records. Having a good contingency plan, formulating a strong back-up system, preparing for other simultaneous technologic emergencies, and planning for post-outage processing, makes a difference (3). Training staff ahead of time to know how to use a paper system may also be prudent. These concerns also extend to research. Having back ups for data and specimens can prevent mother nature from destroying valuable contributions to the scientific community, as happened to many in the wake of Hurricane Katrina in 2005 (4).

Without clean water or reliable electricity, treating patients in need of emergency surgery required urgent transport to the United States (1). Maintaining an adequate supply of sterile surgical equipment for those who stayed on the island also proved challenging because Dr. Zorilla’s team was unable to autoclave instruments.

An unexpected consequence of Hurricane Maria was its effect on drug manufacturers. Baxter pharmaceuticals and Johnson and Johnson both have factories in Puerto Rico and provide numerous medications and additives to the United States (5). This has forced hospital administrations and providers to find alternative medications and new suppliers.

Puerto Rico certainly experienced devastation beyond what most can imagine. The lessons gained from last year’s numerous natural disasters have challenged practitioners to be better clinicians, improve emergency preparedness, maximize ingenuity, and use teamwork to overcome innumerable obstacles.

What will you do to protect your hospital and emergency department when the next natural disaster strikes?

Resources:

  1. Zorilla, CD. The View from Puerto Rico — Hurricane Maria and Its Aftermath. N Engl J Med. 2017 Nov 9;377(19):1801-1803.
  2. Drinking Water. World Health Organization. July 2017. Available online at: http://www.who.int/mediacentre/factsheets/fs391/en/
  3. Minghella, Linda. Be Prepared: Lessons from an Extended Outage of a Hospital’s EHR System. 2013. Available online 3 Jan 2018 at: https://www.healthcare-informatics.com/article/be-prepared-lessons-extended-outage-hospital-s-ehr-system?page=2
  4. Singer, E. Research losses surface in hurricane Katrina's aftermath. Nat Med. 2005 Oct;11(10):1015.
  5. Thomas, K. U.S. Hospitals Wrestle With Shortages of Drug Supplies Made in Puerto Rico. Available online 23 October 2017: https://www.nytimes.com/2017/10/23/health/puerto-rico-hurricane-maria-drug-shortage.htm

Leah Steckler, MD is an Emergency Medicine Resident at The George Washington University Hospital

 

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Published on 2 Comments on “You need to go to the Emergency Department”: The Impact of Outpatient Referral on the ED

Greg Jasani 

January 8, 2018

Many healthcare policy experts have believed that expanding access to outpatient care would lower utilization of emergency departments (EDs).  Yet many outpatient providers often refer their patients to EDs when they believe them to be very sick and potentially in need of hospitalization, and when they don’t have the time or energy to handle their issue in an outpatient setting.  The ED provides a unique service for outpatient providers because, unlike most clinics, it can provide stabilizing and diagnostic interventions, bring in consultants, and even admit patients.

The impact of these referrals on ED volume and flow, however, is less well understood. A recent article in Annals of Emergency Medicine sought to determine whether referral by an outpatient provider was a predictor of illness severity and need for admission.  As the authors noted, if the majority of patients referred to the ED do not ultimately require admission then their diagnostic workup (i.e. blood tests, imaging) could potentially be done in a less acute, cheaper setting.  Conversely, if the majority of outpatient referrals do get admitted then ED providers should consider strategies to expedite these patients’ evaluation and admission.

The authors used data from the National Health Interview Survey, an annual survey administered by the CDC to assess healthcare utilization by Americans.  The survey asks respondents whether they visited an ED in the past 12 months and whether “their healthcare provider advised them to go”.  Of note, the survey does not ask respondents to specify what kind of outpatient provider (i.e. physician, NP, or even specialist) they saw.  From the data, 44,152,870 adults answered that they had visited an ED in the past year.  Of these, 10,913,271 were referred there by their outpatient provider.  The authors found that patients referred to the ED by an outpatient provider were more likely to require admission than those who were not (OR 1.74, 95% CI 1.56 to 1.94).  Even after controlling for other variables, outpatient referral remained an independent risk factor for hospital admission.

This paper shows that outpatient referrals are a significant source of ED volume as they accounted for approximately 25% of visits.  Perhaps more importantly, outpatient referral does appear to be correlated with illness severity as those referred to the ED by an outpatient provider were more likely to require admission compared to those who came in on their own.  This suggests that outpatient providers are assisting ED providers by triaging their own patients and only sending them to the ED when they cannot manage the situation themselves. However, many patients who are referred into the ED for care are ultimately discharged home.

The ED has become the easiest entry point for most unscheduled admissions to the hospital.  While many hope that expanded outpatient provider coverage will reduce ED use, it is important to remember that the ED is an invaluable tool for primary care providers as well.  The study found that on average, referred patients tend to be sicker. However, many patients who are referred into the ED for care are ultimately discharged home, meaning that considerable volume of ED patients could potentially have been treated in outpatient settings.  Going forward, both ED and outpatient providers have to work together to find ways to coordinate care so that when a patient goes from one setting to another, their full healthcare needs are met.

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

Unless otherwise indicated, the content and opinions expressed on this web site are those of the author(s). They are not endorsed by and do not necessarily reflect the views of the George Washington University.
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