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Author: Urgent Matters

Published on Leave a comment on Impedance Threshold Device: revisiting the ROC PRIMED trial
Ameer Khalek
March 7, 2018

 

The management of cardiac arrest is standardized and based on consensus guidelines for all provider levels [1]. In the United States, the most commonly accepted guidelines are those of the American Heart Association. Despite efforts to disseminate these guidelines and educate the public on emergency cardiovascular care, the national rate of survival to hospital discharge for EMS-treated atraumatic cardiac arrest is only 11% [2]. There is significant room for improvement, therefore, it is important to consider innovations in this area.

I sat on the QA/QI committee for my collegiate EMS agency from 2013-2015 and had the opportunity to work with a medical director that encouraged provider involvement in quality improvement [3]. In 2014, we developed and implemented a Clinical Operating Guideline for the use of Impedance Threshold Devices (ITDs), a Class IIa (Benefit >> Risk) recommendation per the 2010 AHA guidelines. In 2015, the AHA updated their guidelines and changed the use of ITDs from a Class IIa (Benefit >> Risk) to Class III (Benefit = Risk) recommendation. By 2017, ITDs were phased out of service. What changed?

Impedance Threshold Devices

The main purpose of CPR is to restore flow of oxygenated blood to the brain and heart. There are two key theories that offer a basis for how this may occur during chest compressions [4]. The “cardiac pump” theory postulates that blood flows because the heart is squeezed between the sternum and the spine. The “thoracic pump” theory postulates that compression of the chest wall causes intrathoracic pressure to exceed extrathoracic vascular pressure and subsequent ejection of blood from the heart into systemic circulation and expiration of air from the lungs. However, the thoracic cavity pressure gradient is attenuated by passive inspiration of air with decompression (i.e., chest recoil) in cardiac arrest.

The ITD is designed to limit this.

Figure 1: Mapping Intrathoracic Pressure [5]

The ITD is a disposable one-way valve that attaches to an airway circuit and regulates intrathoracic pressures to maintain negative intrathoracic pressure during chest compressions by preventing air from entering the lungs between chest compressions, enhancing negative intrathoracic pressure. Often times ITDs will come with a flashing light to concurrently guide ventilation rate.

What Changed?

According to the AHA’s Summary of Key Issues and Major Changes, the ITD’s drop from Class IIa to III recommendation was driven by a single large multicenter randomized clinical trial known as the Resuscitation Outcomes Consortium (ROC) Prehospital Resuscitation using an Impedance Valve and Early vs. Delayed Analysis (PRIMED) trial [6]. The ROC PRIMED included ten sites across the United States and Canada (n = 8,718), and failed to demonstrate any improvement associated with the use of an ITD (compared with a sham device) as an adjunct to conventional CPR. After two years of preliminary data suggesting equivalence of risk and benefit, the National Institutes of Health (NIH) stopped enrollment in the trial [7]. The often erroneously interpreted conclusions of this trial echo throughout the annals of ancillary devices for cardiopulmonary resuscitation and, without much thought, agencies have systematically been taking them off their units. While the ROC PRIMED trial is an excellent resource for driving future academic work, the findings are not actionable and should not inform prehospital practice.

Anyone who has followed CPR research over the years knows that enormous resources are allocated to perform these trials and there are often more questions about study design than conclusions about the interventions being tested [8]. Olasveengen et al. titles this the “why-all-cardiac-arrest-trials-are-neutral”-puzzle, and highlights a few reasons why [9]. The presence of subgroups within a study with significant differences masks any potential positive and/or negative effects within an entire study population. In the ROC PRIMED trial, baseline neurologically intact survival rates ranged from 1.1% in Alabama to 8.1% in Seattle [10]. Is it fair to assume that an ITD will have equal effect in both Alabama and Seattle? Among the ten different sites, there was also variation in BLS CPR protocols being used (i.e., CPR with face mask, 30:2 compression-to-ventilation ratio). Additionally, data collection spanned benchmark outcomes such as ROSC on arrival at ED, survival to hospital admission, and survival to discharge. Researchers did not control for how closely tied these outcomes are to the quality of post-resuscitation care. More than half of included patients received substandard CPR. In a post hoc analysis of their previously published work, researchers stratified patients with high quality CPR and lower the risk of a poor outcome and found a statistically significant benefit from the ITD [11]. With variability in CPR quality, there was no surprise to find variable effect of the ITD.   

Conclusion

The quality of CPR delivered to a patient in cardiac arrest can be a significant effect modifier in clinical trials. Future work in this area should be guided by the notion that the multi-faceted nature of cardiac arrest management is prone to heterogeneity and should be controlled for when designing studies. Additionally, interventions are not mutually exclusive. Research should be refocused on building a systems-based approach to care that considers a combination of therapies.

“Why do we continue to look for a single silver bullet to treat cardiac arrest when we know that every complex disease conquered by modern medicine was done so with a multipronged approach? Isn’t it time to admit that no single intervention […] will significantly improve survival from cardiac arrest, and only a combination of therapies, implemented in a systems-based approach, is the answer?” - Dr. Keith Wesley, Minnesota’s EMS medical director [12]

Future Directions

In Resuscitation, Moore et al. (2017) compared brain blood flow between the Head Up (HUP) and Supine (SUP) body positions during a prolonged CPR effort of 15 min, using ACD CPR and ITD in a porcine model of cardiac arrest and found brain blood flow to be 2-fold higher in the HUP position. These positive findings provide strong pre-clinical support to proceed with a clinical evaluation of ACD CPR + ITD in humans in cardiac arrest [13].

In The American Journal of Emergency Medicine, Niforopoulou et al. (2017) assessed whether the use of an ITD during CPR reduces the degree of post cardiac arrest Acute Kidney Injury (AKI) in a porcine model and found that ITD during Active Compression Decompression (ACD) CPR increased 48-hour survival and decreased the degree of post-cardiac arrest AKI in the resuscitated animal [14].

Ameer Khalek is a MPH student at the GWU Milken Institute School of Public Health

 

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Published on 1 Comment on Patient Experience Measurement in the ED
Ameer Khalek

February 21, 2018

Patient experience encompasses the range of interactions that patients have with their providers and healthcare system.  There are many good reasons to measure and report on patient experience data and subsequently reward providers and hospitals for better performance.  However, patient experience surveys and data collection need to be reliable and valid. Reliability and validity are critical because patient experience data are used for a variety of purposes including managerial decisions (e.g., credentialing, contract renewal, or incentive bonus programs) [1]. In addition, the Centers for Medicare & Medicaid Services (CMS) Hospital Value-Based Purchasing (VBP) plan identifies patient experience as a fundamental marker of value and integrates patient experience into public reporting. Patient experience data will become increasingly important with the implementation of Merit-Based Incentive Payment System (MIPS) under the Medicare Access and CHIP Reauthorization of 2015 (MACRA). In 2016, 44% of healthcare organizations reported having a Chief Experience Officer (CXO) added to their C-Suite with the underlying expectation to financially benefit from higher patient experience scores and positive publicity [2]. Currently, there are no patient experience mandates for emergency medicine. However, these are on the close horizon through the Emergency Department Consumer Assessment of Healthcare Providers and Systems or ‘EDCAHPS’).

A recent study by Pines et al. published in the Annals of Emergency Medicine sheds light on the current state of patient experience data reporting in emergency medicine. The study looked at month-to-month variability and construct validity in patient experience data gathered from 2012-2015 covering 1,758 facility-months and 10,328 physician-months using data from Press-Ganey Associates [5]. Using a retrospective cross-sectional study design, Dr. Pines and his team found that patient experience data varied greatly month-to-month with physician variability being considerably higher. They also found that facility-level scores have greater construct validity than physician-level ones.

Figure 1: Estimated Facility Press Ganey Rank Changes

Across facility-months, 40.8% had greater than 10 points of percentile change, 14.7% changed greater than 20 points, and 4.4% changed greater than 30. For facility-level construct validity, several facility factors predicted higher scores: teaching status; elder, male, and discharged patients without Medicaid insurance; lower patient volume; less requirement for physician night coverage; and shorter lengths of stay for discharged patients.

Figure 2: Estimated Physician Press Ganey Rank Changes

Across physician-months, 31.9% changed greater than 20 points, 21.5% changed greater than 30, and 13.6% changed greater than 40. For physician-level construct validity, younger physician age, participating in satisfaction training, increasing relative value units per visit, more commercially insured patients, higher computed tomography or magnetic resonance imaging use, working during less crowded times, and fewer night shifts predicted higher scores.

“The concept of measuring patient experience and rewarding providers who deliver a better experience is absolutely right on. No one argues with that. Yet what we found is that the data currently being gathered is not particularly reliable nor valid.” – Dr. Jesse Pines [6]

Another concern was around the data collection process which results in low numbers of responses and low response rates. For this study, patient response rates fluctuated from 3.6 – 16%. Corresponding author Dr. Arvind Venkat remarked, “Imagine you conduct a survey, and only the very happy and very unhappy return their surveys. What you get is a very biased sample. That makes it difficult to come to any meaningful conclusions from the data [7].” The researchers proposed several approaches to potentially improve response rates, but more work needs to be done in this area to substantiate practice without affecting the validity of the survey.

Ultimately, the optimization of patient experience data gathering may reduce variability in ED patient experience data and better inform decision-making and quality measurement [8]. Yet, until a solution is found to improve reliability and validity, patient experience data – particularly at the provider-level – needs an overhaul. [9].

Ameer Khalek is a MPH student at the GWU Milken Institute School of Public Health

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

Published on Leave a comment on Patient Navigation for Patients Frequently Visiting the Emergency Department: A Randomized, Controlled Trial

Rose Kleiman

December 11, 2017

Many healthcare systems are trying to find innovate ways to help lower the use of emergency departments (EDs). Often, the focus is on “superutilizers”, patients who frequent the ED many times a year. This cohort of patients only encompasses about 5% of all ED patients, but accounts for about 25% of all ED visits yearly. [i] Reasons for being a frequent user of the ED are multifactorial including complex medical conditions and challenging socioeconomic situations, but often results in more fragmented patient care and higher costs to the healthcare system.

A new study from the University of Tennessee[ii] aimed to help keep frequent ED users from needing the ED through the use of a patient navigator program. The research team created a patient navigator program that worked within the ED to help patients review diagnoses and prescriptions, arrange follow-up appointments and transportation, and identify relevant community resources. The navigator would meet with the patient to perform these tasks during the initial visit, any following ED visit, and by telephone within 2 weeks and 12 months of the initial visit.

Superusers were defined as any patient presenting to the Erlanger Baroness ED for their fifth visit or more within a 1-year period. Once a patient was properly consented for participation in the pilot, they were assigned to the control arm or the experimental arm. The control group also received a call from a research assistant at the 2 week and 12-month time post the initial visit to the ED.

At the two-week follow-up call, visits to a primary care physician (PCP) were reported in 47% of patients in the treatment group and 43% in the control. However, at the twelve-month follow-up, phone survey results found that the experimental group had seen their PCP an average of 6.42 visits (95% CI = 5.14–7.70) over the 12-month follow-up period, which was significantly more than the 4.07 visits (95% CI = 3.38–4.76) over the 12-month follow-up in the control group (p = 0.0013). This suggests that the navigator had a positive influence on getting patients to utilize their PCP to a greater extent.

Community ED visits decreased during the 12-month study period, compared to the 12 months prior to enrollment (2,249 visits prior to enrollment to 2,050 visits 1 year after enrollment, 8.8% decrease) study. While there was a decrease in in ED use in both arms of the study, there was a greater decrease in ED visits from the pre-enrollment year to post-enrollment year in the treatment group (1,148 visits to 996 visits, 13.2% decrease) compared to the control group. (See Figure 1)

Figure 1: Emergency department visits pre- and post-enrollment

The research team reported that the cost of the patient navigator program was $34,808, which consisted of salary, benefits, and program administration costs. Overall health system costs (ED and hospital, excluding ED physician costs) for all 282 patients went from $3,925,233 in the year prior to enrollment to $3,130,510 in the follow-up 12 months (20.2% decrease; 95% CI = 19.5%–20.9%). While costs for ED visits did go down for both study arms, costs for ED visits had a greater decrease in the treatment group ($1,267,280 to $930,584, 26.6% decrease, 95% CI = 26.1%–27.0%) versus the control group ($1,556,536 to $1,283,590, 17.5% decrease, 95% CI = 17.1%–17.9%; p < 0.0001).

Only two other studies have looked at the use of a patient navigator program to help decrease frequent use of the ED and the results have been conflicting[iii] [iv]. But, the University of Tennessee team has shown with this pilot that patient navigators may be an effective way to reduce some of the frequent use and associated costs of the ED. The researchers do note that these findings could represent a placebo effect by entering the study alone might or could represent a regression to the mean for both groups.

As we continue to look for innovative ways to help some of the neediest patients is the healthcare system, patient navigators are uniquely positioned to play an integral role in the changing health care environment by facilitating access to care, as well as addressing language and cultural barriers and may be a key component of helping frequent users of the ED manage their healthcare and social needs.

[i] LaCalle E, Rabin E. Frequent users of emergency departments: the myths, the data and the policy implications. Ann Emerg Med 2010;56:42–48.

[ii] Seaberg, D., Elseroad, S., Dumas, M., Mendiratta, S., Whittle, J., Hyatte, C., & Keys, J. (2017). Patient Navigation for Patients Frequently Visiting the Emergency Department: A Randomized, Controlled Trial. Academic Emergency Medicine, 24(11), 1327-1333.

[iii] Spillane LL, Lumb EW, Cobaugh DJ, Wilcox SR, Clark SR, Schneider SM. Frequent users of the emergency department: can we intervene? Acad Emerg Med 1997;4:574–80.

[iv] Shumway M, Boccellari A, O'Brien K, Okin RL. Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med 2008;26:155–64.

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

Published on Leave a comment on Is urgent primary care follow-up after ED discharge realistic?
Evan Kuhl, MD

December 4, 2017

More than two thirds of patients seen in an emergency department (ED) leave with instructions to follow-up, often for further diagnosis or treatment of chronic conditions. This practice is supported by numerous guidelines, and many practitioners rely on presumed access to urgent follow-up to safely discharge their patients. Additionally, time-specific discharge instructions have been viewed as a defense against potential litigation, regardless of the patient’s ability to comply. A new article by Chou et al published in the Annals of Emergency Medicine expands on previous research evaluating how often patients are actually able to obtain urgent follow-up, and how insurance status and condition impacts this ability.

To determine if prompt primary care appointments were available and whether this availability differed by insurance type, the researchers performed a “secret shopper” study to make appointments for simulated patients. This follows two previous studies in 1994 and 2005, where similar methods were used to determine insurance type impacted the ability to obtain follow-up. Most recently, the 2005 study by Asplin et al found that only 34% of Medicaid patients could obtain an appointment within 7 days, while privately insured patients were successful in 64% of cases. The new Chou et al study is the first to evaluate access since the passage of the ACA, which provided coverage to approximately 20 million more people, and approximately 241,000 newly insured patients in New Haven, Connecticut where the research data was collected.

In a “secret shopper”, or simulated patient survey, the primary objective to determine the differences in appointment availability and wait time by insurance status.  A primary outcome is the proportion of calls that can obtain an appointment within 7 days. All active primary care practices in New Haven, Connecticut were included in the study, totaling 92 offices. After excluding OB-GYN, Veterans Affairs, HIV/AIDS clinics, student health clinics, and mental health clinics, 53 active practices were included in the simulated patient survey.  The study utilized two scenarios; uncontrolled hypertension and non-traumatic low back pain. Electronic health records were created for each simulated ED visit as most primary care offices would have access to these documents. Two callers were trained to use standardized call scripts to present either of the two scenarios, while altering between commercial insurance, a state exchange plan, or Medicaid. This created 6 different combinations between insurance type and clinical condition. Each practice was called 6 times, once with each combination, between October 2015 and May 2016. The calls were placed into scheduled sets so as to avoid offices from recognizing the callers’ voices, and the order of calling was randomized within each set.

The callers completed 604 calls during the study period, with an adjusted 7-day appointment rate of 30.7% and adjusted overall appointment rate of 68.2%. The overall median wait time was 8 days, with an adjusted mean wait time of 16.4 days. Because the researchers were utilizing the same offices multiple times, they created estimating equation models to calculate mean waiting time and adjusted 7-day appointment rates. The researchers found that Medicaid patients had a lower 7-day appointment rate (25.5% vs 35.7%) and lower overall appointment rate (53.5% vs 77.8%) than commercial insurance. However, there was no significant difference in appointment rates between commercial insurance and state exchange insurance. Although low back pain scenarios had a lower 7-day appointment rate (27.6% vs 33.7%) there was no difference in overall appointment rates.

The most common reason given for declining an appointment overall was that the practice was not accepting new patients (41.9% of all declined requests) while Medicaid patients were most likely to be told their insurance was not accepted (57.4% of declined Medicaid requests). During debriefing, both callers noted anecdotally that they were confronted with more questions about medication use when calling with back pain, and were declined by staff citing they did not provide pain management or back pain care. Although this study was performed in a single city with access to one of the oldest state insurance exchanges and cannot be generalized to many populations, the results are similar to other multi-state studies and provide a comparison to pre-ACA data.

This article provides an interesting and informative perspective on the current state of urgent follow-up availability. When taken in context with the previous research, the Chou et al study shows there is a continued inequality in access to follow-up care, as well as a practical limit to how soon patients are able to obtain an appointment, despite the recommendation of an emergency provider.

Acknowledging the reality that most patients are unable to follow-up within the classically prescribed 2-3 days is an important step in recognizing and understanding the complexities of providing safe transitions from the ED. Furthermore, as the authors highlight, there is a need for improved partnerships between the emergency department and primary care providers to improve primary care access and integration.

Evan Kuhl, MD is an Emergency Medicine Resident at The George Washington University Hospital

Published on Leave a comment on Buprenorphine as treatment for opioid withdrawal

Leah Steckler, MD

November 20th, 2017

According to the Centers for Disease Control, opioids were involved in 33,091 deaths in 2015 and overdoses have increased four-fold since 1999, including both illicit and prescribed opioid medications (1). This dramatic increase in mortality has persisted despite prescribers writing fewer prescriptions for opioids in the past few years (2).  It is possible that fewer opioid prescriptions may lead to more patients experiencing withdrawal.  Current practice approaches in the emergency department (ED) tend to focus more on symptomatic treatment with anti-emetic and anti-diarrheal agents, and referral to rehabilitation services (3).  The standard of care does not currently include opioid agonist-antagonists, like buprenorphine, in the acute period for the management of these patients. The unpleasant effects of withdrawal undoubtedly contribute to opioid addiction. As such, improving pharmacologic methods to control withdrawal symptoms may provide another means of fighting this epidemic.

An article in Annals of Emergency Medicine by Love et al. (4) presents an emergency medicine-focused snapshot of a recent Cochrane Review assessing our current opioid withdrawal treatments (5). This Cochrane Review analyzed data from 27 studies comparing buprenorphine to tapered methadone, and studies comparing buprenorphine with clonidine (an alpha-2 adrenergic agonist used commonly to treat withdrawal symptoms).

Love and colleagues suggest that buprenorphine administration in the ED may be an appropriate intervention for opioid withdrawal. Fourteen of the studies compared buprenorphine and alpha-2 adrenergic agonists as pharmacologic withdrawal management. Using data extraction, subgroups were analyzed and the results showed that patients treated with buprenorphine had significantly lower withdrawal scores and greater number of days in treatment than patients treated with alpha 2-adrenergic medications. The authors concluded that the number of patients needed to treat with buprenorphine was four in order for one additional patient to reach withdrawal treatment (4) (Figure 1).

Figure 1: Buprenorphine versus alpha2-adrenergic agonists for acute opioid withdrawal (4)

Upon reviewing the above information, it is clear that limitations still exist with the use of buprenorphine to treat opioid withdrawal. Buprenorphine is not without risk and may cause dangerous adverse effects including hypotension, derangements in liver function, and respiratory depression (6). It is important that prescribers are comfortable with the evidence behind a medication, that they understand appropriate dosing regimens, and that the medications are safe for patients. Further, a provider cannot prescribe buprenorphine without taking an 8-hour course and receiving a certificate from the Drug Enforcement Agency (7). Additionally, this topic has not been well studied in the ED population, and there is always the risk of patients becoming addicted to the treatment for their addiction (8). Starting withdrawal treatment in the ED may help to bridge opioid users to outpatient treatment and contribute to our country’s mission to stave off future opioid abuse. Continued research on buprenorphine use in the ED is certainly worthwhile.

Resources:

  1. Drug Overdose Death Data. 2014-2015 Death Increases. CDC. Available from: https://www.cdc.gov/drugoverdose/data/statedeaths.html
  2. S. Prescribing Rate Maps. Total number and rate of opioid prescriptions dispensed, United States, 2006-2016. CDC. Available from: https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html
  3. Tintinalli Burillo-Putze G, Miro O. Opioids. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.proxygw.wrlc.org/content.aspx?bookid=1658&sectionid=109414267. Accessed November 10, 2017.
  4. Love, J, Perrone, J, Nelson, L. Should Buprenorphine Be Administered to Patients with Opioid Withdrawal in the Emergency Department? Ann Emerg Med. Published online November
  5. Gowing L, Ali R, White JM, et al. Buprenorphine for managing opioid withdrawal. Cochrane Database Syst Rev. 2017;2:CD002025.
  6. Epocrates. Available from: https://online.epocrates.com/drugs/7468/Belbuca
  7. Buprenorphine Waiver Management. Available from: https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management
  8. Addicted to a Treatment for Addiction. New York Times. 2016. https://www.nytimes.com/2016/05/29/opinion/sunday/addicted-to-a-treatment-for-addiction.html

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

 

Published on Leave a comment on Emergency Care Innovation of the Year: ED Telehealth Express Care Service
Ameer Khalek
November 13, 2017

 

If you haven’t heard by now, Urgent Matters holds an annual meeting at the American College of Emergency Physicians (ACEP) Scientific Assembly. While the exact theme changes from year to year, the meeting serves to bring together thought-leaders and innovators from the emergency medicine community. Thanks to Philips Blue Jay Consulting and Schumacher Clinical Partners, we are also able to acknowledge teams for developing and implementing effective solutions to common issues facing the emergency care community through our “Emergency Care Innovation of the Year Award.” This year, we received over 20 submissions and our reviewers narrowed them down to one winner and three honorable mentions.

Jesse Pines, MD MBA MSCE – Program Director, Urgent Matters
Rahul Sharma, MD MBA CPE – EM Physician-in-Chief & Medical Director, Strategic Initiatives
Hansen Hsu, MD – Director, EM Informatics & Co-Director, EM Telehealth Services
Peter Greenwald, MD MSC – Director, Telehealth QA & Co-Director, EM Telehealth Services
(Left to Right)

This year’s winner was New York Presbyterian/Weill Cornell Medical Center’s Emergency Department (ED) Telehealth Express Care Service. The ED Telehealth Express Care Service is an innovative ED-based telehealth program designed to streamline emergency care, reduce length of stay (LOS), and improve patient experience for patients with low acuity complaints.

The process for ED Telehealth Express Care patients begin as it would for any other ED patient: an in-person triage and assessment. A registered nurse speaks with the patient and categorizes the severity of their medical complaint. Next, an Advanced Practice Provider (Physician Assistant or Nurse Practitioner) evaluates the patient, performs the Medical Screening Exam which is required for all ED visits, and decides whether the Telehealth program would be medically appropriate. Qualification for the Telehealth Express Care Service is based on set criteria (available in the UM Toolkit). Participation by the patient is voluntary. If the patient declines, a physician will examine them in-person. The telehealth encounter takes place with the on-call Telehealth Physician, a board certified Emergency Medicine faculty member. Evaluation, diagnosis, treatment, and education are discussed at-length, with family members present if desired. Discharge instructions are printed directly at the end of the visit by the physician with any prescribed medications sent electronically to a pharmacy of the patient's choice.

So, why would someone physically go to an emergency department, only to be seen by a remote physician through a screen? Dr. Sharma responds in an Urgent Matters podcast:

“When was the last time you actually went to the bank and went to the teller instead of the ATM to get cash? You don’t, you only go in when you need a certified check or something complicated.”

The data supports him. The ED Express Care Service has been in place since July 2016 is available at two of six EDs at New York Presbyterian: Weill Cornell - a Level 1 Trauma Center, and Lower Manhattan - a community hospital. Together these hospitals see an annual volume of over 140,000 visits. To date, over 4,000 patients have been through the ED Express Care Service with impressive results. Express Care Service has helped reduce wait times for low-acuity patients from 2.5 hours to an average 39 minutes from arrival to discharge. The project also helps to establish primary care appointments, and twenty percent of patients receive follow-up appointments via the in-house ED patient navigator program with a primary care physician or sub-specialist prior to discharge. From the first year of data, Express Care patients, compared to those receiving a traditional fast track evaluation, were younger (median age: 38 [IQR, 27-54] vs. 43 [31-58]; P<0.001) and more likely to be male (52% vs. 46%; P<0.001), Express Care patients had less acute illness as measured by triage severity score (ESI 4 or 5: 97% vs. 84%; P<0.001), and more likely being treated for wound check/suture removal and infectious illness. Express Care patients were less likely to have x-rays preformed as part of their ED evaluation (24% vs. 42%; P<0.001). Express Care patients were treated and released more quickly than fast track patients (median time door to discharge 39 minutes as compared to 120 minute). Express Care patients were less likely to return within 72 hours, and no Express Care patient returning within 72 hours required admission to the hospital. There was a trend to higher Press Ganey satisfaction among Express care patients as compared to fast track ED patients (median: 100 [87-100] vs. 89 [74-100]; P=0.15). Another analysis listed in their submission comparing older patients to younger patients in express care found that although Express Care patients trended younger than traditional ED pathway patients on average, patients 60 and older comprised 24% of the total Express Care population, indistinguishable from the percentage of people 60 and older in the conventional treatment fast track area. Among patients 60 years and over seen in Express Care, the average age was 72. There were no significant differences by age group with respect to 72 hour returns to the ED and a low likelihood for a change in treatment plan on return. In addition to eliciting patient feedback regarding satisfaction with the ED experience, the team surveyed participating physicians about their telemedicine background and experience with the program, with most physicians reporting a significant increase in comfort and positivity about telemedicine patient encounters.Future Direction

At the Urgent Matters meeting, Dr.’s Rahul Sharma, Peter Greenwald, and Hanson Hsu spoke on plans to expand the project by incorporating nursing homes consultation, telehealth kiosks in NYC pharmacies, and paramedic telemedicine visits for CHF patients. Dr. Greenwald also briefly mentioned the value of engaging with insurance companies to provide coverage for virtual urgent care as part of a benefits package. Dr. Ali Raja, Vice Chairman of the Department of Emergency Medicine at Massachusetts General Hospital was quoted in the Wall Street Journal saying, “Ten years from now, tele-emergency medicine will be the standard around the country. We’ll still have emergency departments for those patients who are critically ill, but I think we’re all headed in this direction.”

Personally, I would like to extend my congratulations to the ED Express Care team for their innovative, patient-centered, and value-driven work. Make sure to look out for an upcoming webinar with the New York Presbyterian/Weill Cornell Medical Center team (subscribe here).

For more:

Ameer Khalek is a MPH student at the GWU Milken Institute School of Public Health

Published on Leave a comment on Preparing for Tragedy: Lessons learned from Charlottesville

Greg Jasani 

November 8, 2017

At 1:42 pm on August 12th, 2017, a speeding car rammed into a group of protestors who had gathered in Charlottesville, Virginia, resulting in many injuries.  In the ensuing hours, the University of Virginia Health System (UVAHS) would be called upon to provide care to all of the victims of the day’s violence.  A recent article in ACEPNow, authored by some of the physicians there that day, details how UVAHS handled the sudden influx of critically injured patients. Their response to the day’s events, and the decisions made in the days before, provides an excellent example of how to provide critical care and coordination during a mass casualty event (MCE).

The emergency department at UVAHS had one advantage that many EDs facing a MCE do not; they had prior warning.  The white supremacist rally, and expected counter rally, had been scheduled in advance.  Due to this, the ED was able to take proactive steps to better prepare themselves for the anticipated surge in volume.    The ED reviewed and updated their emergency notification procedures as well as each member’s roles in the medical care team.  They also created two additional shifts around the event to increase the number of providers.  Other departments that expected to be impacted by the protests (ie anesthesia and critical care) also underwent similar preparations.

Outside of the ED, the UVA hospital also took active steps to prepare for the increased surge.  One of the areas that the hospital took active steps to optimize was capacity.  The hospital leadership decided to limit non-urgent procedures 48 hours before the protests.  Additionally, transfers into the hospital were also curtailed.  These actions freed up significant inpatient space that allowed patients to move out of the ED faster.  Also, additional patient care areas were created; the hospital lobby was converted into a triage area for the ED and an invasive radiology recovery area adjacent to the ED was used as an admissions holding area.

The ED also worked closely with community EMS, firefighter, and law enforcement personnel.  In addition to reviewing and updating their operating procedures, UVAHS took the additional step of creating a command center to better coordinate everyone’s response to the event.  The command center had an incident commander as well as general staff positions (ie, clinical operations, logistics, plans, public information, and communications), each responsible for their specific area of UVAHS function.  The command center closely monitored events at the protests through radio, real-time video monitoring, and even social media.  Thus, within three minutes of the car hitting the protestors, the command center was alerted and began coordinating the response.

Ten patients had to be admitted (to either the OR or critical care areas) and nine were treated and discharged by the ED.  One woman, Heather Heyer, sadly died from her injuries in the ED.  Yet perhaps the most astonishing thing about that day’s events was how little it impacted the operation of the UVA ED.  While caring for the victims of the day’s violence, the ED continued to treat non-event patients with no real disruption of service.  Additionally, within two hours of initial notification of the MCE, the ED returned to normal operations.

Unfortunately, violence came to Charlottesville and the ED had to provide urgent care to many seriously injured patients.  Yet the ED managed to respond swiftly and likely kept the death rate from going higher than it did.  While the skill and courage of the ED providers definitely deserve praise, it was the thorough planning and coordination that allowed the health system to react appropriately and operate smoothly during that time of high stress.  This incident shows that, as much as possible, health systems should take pro-active steps to prepare themselves when it’s likely that a MCE will come to their community.

References

Brady W, Berry T, Ginsburg J, Iftikhar S, Izadpanah K, Lindbeck G, Sutherland S, O’Connor R.  UVAHS Emergency Team Helps Victims in Charlottesville Tragedy.  ACEPNow [Internet]. 2017 Oct 15.  Available from: http://www.acepnow.com/article/uvahs-emergency-team-helps-victims-charlottesville-protest-tragedy/

 

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

Published on Leave a comment on Earlier Discharge for Chest Pain Patients

Greg Jasani 

October 16, 2017

Chest pain is one of the most common chief complaints of patients who present to emergency departments.  It accounts for over 7 million visits and is the most common chief complaint in patients over the age of 65.[i],[ii] It is also presents a diagnostic challenge for emergency medicine physicians.  The differential for chest pain is broad and includes deadly conditions such as myocardial infarctions and benign ones such as costochondritis.  Due to fear of missing cases of acute coronary syndrome (ACS) or acute myocardial infarction (AMI), many patients undergo lengthy ED workups or are admitted for further observation or testing. However, ultimately, only a small number of patients are found to have ACS or MI.[iii] One of the great challenges of emergency medicine is finding a way to efficiently and safely determine which patients need urgent intervention and which can be safely sent home.

The European Society for Cardiology guidelines recommend the use of a 0-hour/1-hour strategy (class 1 recommendation) where AMI is considered ruled out either if a high-sensitivity cardiac troponin T (hs-cTnT) is < 5 ng/L at presentation or if 0-hour hs-cTnT is < 12 ng/L together with a 0- to 1-hour increase < 3 ng/L.[iv]  Several studies have demonstrated a very high negative predictive value for the 0 and 1 hour troponin rule.[v],[vi]  However, some studies have shown a less than 99% sensitivity[vii],[viii], which has led to some questioning as to its usefulness as an adequate diagnostic tool.  As a result, some have proposed combining the 0 and 1hour troponin rule with EKG data and the TIMI score to increase the sensitivity.

Mokharti et al sought to determine whether this combination was indeed a useful diagnostic tool for detecting AMI.[ix]  Their study, published in Academic Emergency Medicine, is the first to evaluate whether the 0 and 1 hour troponin rule with an EKG and low TIMI score is a reliable tool to safely identify and discharge chest pain patients, which they referred to as the Accelerated Diagnostic Protocol (ADP).  If the troponins and EKG were negative and the calculated TIMI score was < 1, the ADP would be considered negative and the patient would be considered low risk and potentially safe for discharge.  Their study was a prospective observational study.  Patients who presented with non-traumatic chest pain had a 0 and 1 hour troponin levels drawn as well as an EKG and calculated TIMI score.  Although the ADP was not used to guide the management of these patients, the authors then determined if the ADP was predictive of risk.

The primary endpoint of this study was the presence of a Major Adverse Cardiac Event (MACE) within 30 days of initial presentation.  In total, 1,020 patients were analyzed.  MACE occurred within 30 days in 119 patients.  The majority of these were AMI (n=77) or unstable angina (n=38).  Among patients who were ADP-negative, only 0.5% of patients had a MACE; the ADP missed 2 patients who both had unstable angina.  The ADP did not miss any patients who were experiencing an AMI during their visit.

                       One interesting point of discussion with regards to this study is their use of the TIMI score over the HEART score. The TIMI score is designed to identify patients at high risk of experiencing a MACE and even offers management guidelines.  The HEART score, by contrast, is specifically focused on identifying patients at low risk of experiencing a MACE.  Although a relatively newer risk stratification tool, the HEART score has been validated in multiple studies[x],[xi] and it has even been shown to be superior to the TIMI score in determining which patients are experiencing a MACE.[xii]  Given that this study sought to identify and discharge low risk patients it would seem like the HEART score would fit in better with the ADP.  The authors do not comment on their decision to use the TIMI score over other risk stratification tools.  Whether the HEART score improves the results seen with the ADP is certainly worth investigating further.

With respect to the Mokharti study, it represents the first study to evaluate the performance of the 0 and 1 hour troponin rule-out strategy when combined with clinical risk stratification tools.  The results of this study suggest that using the ADP could potentially lead to expedited identification and discharge of low risk chest pain patients.  Of course, further studies will be needed to evaluate the ADP being used in actual clinical practice.  Yet this study does raise the exciting possibility that, in the near future, low risk chest pain patients can be safely screened and cleared for discharge in an hour, leading to considerable savings for both patients and the healthcare system.

[i] National Hospital Ambulatory Medical Care Survey: 2010 Emergency Department Summary Tables. CDC. Available from: http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf.

[ii] National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey, 2010 Emergency Department Summary Tables: Table 13. Twenty Leading Primary Diagnosis Groups for Emergency Department Visits, by Patient Age and Sex: United States, 2010. Available at: www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_ tables.pdf. p. 5.

[iii] Penumetsa SC, Mallidi J, Friderici JL, Hiser W, Rothberg MB. Outcomes of patients admitted for observation of chest pain. Arch Intern Med 2012;172:873–7.

[iv] 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 STSegment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016;37:267–315.

[v] Mokhtari A, Borna C, Gilje P, et al. A 1-h combination algorithm allows fast rule-out and rule-in of major adverse cardiac events. J Am Coll Cardiol 2016;67:1531–40.

[vi] Mokhtari A, Lindahl B, Smith JG, Holzmann MJ, Khoshnood A, Ekelund U. Diagnostic accuracy of high-sensitivity cardiac troponin T at presentation combined with history and ECG for ruling out major adverse cardiac events. Ann Emerg Med 2016;68:649–58.e3.

[vii] Mueller C, Giannitsis E, Christ M, et al. Multicenter evaluation of a 0-hour/1-hour algorithm in the diagnosis of myocardial infarction with high-sensitivity cardiac troponin T. Ann Emerg Med 2016;68:76–87.e4.

[viii] Pickering JW, Greenslade JH, Cullen L, et al. Assessment of the European Society of Cardiology 0-hour/1-hour algorithm to rule-out and rule-in acute myocardial infarction. Circulation 2016;134:1532–41.

[ix] Mokhtari A, Lindahl B, Schiopu A, Yndigegn T, Khoshnood A, Gilje P, et al. A 0-Hour/1-Hour protocol for safe, early discharge of chest pain patients. Acad Emerg Med 2017; 24(8): 983-992

[x] Backus B, Six A, Kelder J, Bosschaert M, Mast E, Mosterd A, Veldkamp R, ,et al. A prospective validation of the HEART score for chest pain patients at the Emergency Department. Intl J Cardiol 2003; 168(3): 2153-2158

[xi] Backus B, Six A, Doevendans P, Kelder J, Steyerberg E, Vergouwe Y. Prognostic Factors in Chest Pain Patients: A Quantitative Analysis of the HEART Score. Crit Pathw Cardiol 2016; 15(2): 50-55

[xii] Poldervaart J, Langedijk M, Backus B, Dekker I, Six A, Doevendans P et al. Comparison of the GRACE, HEART, ,and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department. Intl J Cardiol 2017; 227(15): 656-661

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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