Tag: Greg Jasani

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.

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

Greg Jasani 

November 8, 2017

At 1:42 pm on August 12^th, 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/

 

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

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

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

Greg Jasani 

August 14, 2017

Malpractice is a major concern in the specialty of emergency medicine.  Emergency medicine physicians must make quick decisions in the setting of limited time, limited information, and high acuity. EDs are a common source of malpractice liability in the American healthcare system.[i] One study found that the median payout of emergency medicine malpractice claims was $220,000.[ii]  To reduce risks, 9 in 10 physicians report engaging in “defensive medicine”, specifically using tests and/or procedures for the sole purpose of reducing the risk of malpractice liability.[iii]

Malpractice concerns also have adverse effects on the wellness and mental health of emergency medicine physicians. On average, emergency medicine physicians spend 50.7 months of their careers involved in litigation.[iv]  Additionally, over 75% of emergency medicine physicians will be named in a malpractice lawsuit at some point during their careers.[v]  A malpractice claim can have devastating effects on a physician’s well being: “medical malpractice stress syndrome” increases anxiety and depression, and can even lead to thoughts of suicide among providers.[vi]

In a recent article in the Annals of Emergency Medicine, Carlson et al studied physician and hospital factors associated with being named in a malpractice lawsuit.[vii]  They conducted a retrospective cross-sectional study on data collected from a national emergency physician group that managed 87 EDs in 15 states.  The authors looked at data from January 2010 through June 2014.  Physician factors measured were years in practice (excluding residency), board certification, and majority night shift work.  Other factors measured were median monthly RVUs generated per hour, data on patient experience, median monthly physician admission rate, total number of patients treated by a physician, and working in multiple EDs.  The authors chose these variables because they have a conceptual and perceptual links with the risks of malpractice.

The authors examined over 9,000,000 cases treated by 1,029 different physicians.  During the study time, 90 of the included physicians were named in malpractice suits (98 total).   Of the 9 independent variables analyzed, only increasing years in practice and total patients treated as an attending physician were associated with being named in a malpractice claim.  These results are interesting for several reasons.  Traditionally, many believed that more years in practice would decrease risk of being named in malpractice claim as a physician would be more experienced and less prone to mistakes.  However, this study found that an emergency medicine physician’s risk of being named in a malpractice lawsuit increased 4% every additional year that he or she practiced.  The authors are unable to account for this finding but consider that this could be due to the constantly evolving nature of medicine and the need for providers to receive continuing medical education after residency.  Further studies exploring the associations between years in practice and malpractice, and the possible role of post-residency education, are certainly warranted.

The fact that increased total number of patients treated leads to increased malpractice risk is less surprising.  More patients means more exposure to a clinical outcome that could lead to a malpractice claim.  The fact that patient satisfaction was not related to malpractice risk is also interesting.  Research from other medical specialties has shown that patient complaints about physician communication are related to higher malpractice risk.[viii]^,[ix]  However this trend does not appear to apply to emergency medicine providers in this study.  The authors posit that this could be due to the brief interactions and lack of relationship building between providers and patients in the emergency department.

This article shows that emergency medicine physicians who have practiced longer and who see more patients are more likely to be named in a malpractice lawsuit.  Malpractice claims are, unfortunately, inevitable due to the environment that emergency medicine physicians operate in.  Malpractice litigation also places a heavy burden on both the health system and the providers.  As with many things in medicine, one of the first steps is identifying who is at risk.  This article helps advance our understanding of which physicians are at a higher risk; knowing this will be invaluable in developing strategies for making the healthcare system safer and hopefully reducing the number of malpractice claims filed.

[i] Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006; 354:2024–33.

[ii] Cohen D, Chan S, Dorfman M. Malpractice claims on emergency physicians: time and     money. J Emerg Med. 2012; 42(1): 22-27

[iii] Bishop T, Federman A, Keyhani S. Physician’s views on defensive medicine: a national survey. Arch Intern Med. 2010; 170: 1081-1083

[iv] Seabury S, Chandra A, Lakdawalla D, et al. On average, physicians spend nearly 11 percent of their 40-year careers with an open, unresolved malpractice claim.Health Aff (Millwood). 2013; 32: 111-119

[v] Jena A, Seabury S, Lakdawalla D, et al. Malpractice risk according to physician specialty. N Engl J Med. 2011; 365: 629-636

[vi] Sanbar S, Firestone M, Medical malpractice stress syndrome. Available at: https://www.acep.org/uploadedFiles/ACEP/Professional_Development/Faculty_Development/Medical%20Malpractice%20Stress%20Syndrome%20article%20for%20web.pdf.

[vii] Carlson J, Foster K, Pines J, Corbit C, Ward M, Hydari M, et al. Provider and practice    factors associated with emergency physicians’ being named in a malpractice claim. Ann Emerg Med. 2017: 1-8

[viii] Hickson G, Federspiel C, Pitchert J, et al. Patient complaints and malpractice risk. JAMA. 2002; 287: 2951-2957

[ix] Cydulka R, Tamayo-Sarver J, Gage A, et al. Association of patient satisfaction with complaints and risk management among emergency physicians. J Emerg Med. 2011; 41: 401-405

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

 

Greg Jasani

August 2, 2017

Febrile neutropenia is a well known side effect of chemotherapy and patients with it often present to emergency departments.  Standard of care has been to admit these patients for aggressive IV antibiotics. However, recent research has suggested that a certain subset of these patients can be considered low risk and managed as outpatients[1]^,[2].  Two risk stratification tools, the Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores, have been proposed to identify these low risk patients[3].  While these scores have been studied and validated in the inpatient setting, there has been no research about whether these risk stratification tools are valid in the emergency department.  A recent article in Annals of Emergency Medicine by Coyne et al examined whether these scores could be used to accurately identify low-risk febrile neutropenic patients in the emergency department.

The study was a retrospective cohort study conducted in the emergency departments of two academic hospitals.  It examined the medical records of all patients who presented with febrile neutropenia to the two emergency departments between June 2012 and January 2015.  Inclusion criteria for the study were a fever of greater than 100.4F and an absolute neutrophil count of less than 1,000.  Only patients with febrile neutropenia believed to be secondary to chemotherapy were included.  In total, the authors reviewed 230 charts in their final analysis.  The primary outcomes of the study were inpatient length of stay, level of care, clinical deterioration, clinical deterioration, positive blood cultures, and death.  For the purposes of the study, the authors considered patients who did not experience any negative outcomes during their admission to be truly low risk.

Source: Coyne et al.  Application of the MASCC and CISNE risk-stratification scores to identify low-risk febrile febrile neutropenic patients in the emergency department. Ann Emerg Med.  2017; 69(6): 755-764

For every patient, the authors calculated both the CISNE and MASCC scores to determine which was more accurate in identifying low-risk patients (See the Figure for details on how to calculate these scores).  Ultimately, they found that the CISNE score was more accurate in identifying febrile neutropenic patients in the ED did not have an adverse event while hospitalized.  The score was 100% specific in identifying all negative outcomes except for positive blood cultures for which the specificity was 97.4%.  The positive predictive value of the CISNE score in the identification of low risk patients was found to be 98.1%.  The MASCC score was less accurate at identifying low risk patients.  The specificity for identifying low risk patients was only 54.2% and the positive predictive value was 84%.

This study provides evidence that the CISNE score can be used to accurately identify low-risk febrile neutropenic patients in the emergency department.  The CISNE score was also found to be superior to the MASCC score.  Although this study was a retrospective chart review, it provides evidence that the CISNE score may be helpful in determining which patients are at low risk of having adverse outcomes associated with their condition.  There is growing evidence to suggest that these patients can be managed successfully as outpatients[4]^,[5].  Managing them as outpatients would not only save hospital resources but prevent exposing these patients to potentially harmful hospital acquired infections.  While this paper is not enough justification to discharge these patients directly from the emergency department it does show that further research into this area is warranted and provides a potentially helpful risk stratification tool for emergency medicine physicians to help guide clinical decision making.

[1] Cooksley, T., Holland, M., and Klastersky, J. Ambulatory outpatient management of patients with   low risk febrile neutropaenia. Acute Med. 2015; 14: 178–181

[2] Gea-Banacloche, J. Evidence-based approach to treatment of febrile neutropenia in hematologic malignancies. Hematol Am Soc Hematol Educ Program. 2013; 2013: 414–422

[3] Coyne C, Le V, Brennan J, Castillo E, Shatsky R, Ferran K, et al.  Application of the MASCC and CISNE risk-stratification scores to identify low-risk febrile febrile neutropenic patients in the emergency department. Ann Emerg Med.  2017; 69(6): 755-764

[4] Flowers, C.R. and Karten, C. Communicating safe outpatient management of fever and neutropenia. J Oncol Pract. 2013; 9: 207–210

[5] Pherwani, N., Ghayad, J.M., Holle, L.M. et al. Outpatient management of febrile neutropenia associated with cancer chemotherapy: risk stratification and treatment review. Am J Health Syst Pharm. 2015; 72: 619–631

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