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CLICK ON THE LINK, VERY NICE POST ON CHARTING EFFICIENCY!
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THAT LINK RIGHT ABOVE THIS LINE.
CORD/CDEM/EMRA/SAEM video on Transitions of Care. Take a look, consider using on your next rounds!
https://www.youtube.com/watch?v=7B7p_krIEkU&feature=youtu.be
New article here on screening for sex trafficking in the ED. Interesting and very practical study on screening our patients. Only takes a few questions to possibly save someone’s life.
Hey, all,
There is multimedia for this month’s journal club, so I wanted to post it all in one place. The theme will be impossible decisions in the department (eg ED thoracotomy without surgery backup, but we’ve talked about that issue ad nauseum). In my mind, it’s best to think about how you’ll approach impossible decisions now, before they show up overnight on single coverage in the middle of nowhere. Other ideas for discussion are welcome.
Closing the emergency department: EP Monthly, Diversion 1, Diversion 2
Crashing VP shunt patient: Tapping a shunt article, Tapping a shunt video
Epidural hematoma: Burr hole for epidural hematoma article, Burr hole presentation, Video of a burr hole
Here is a nice summary of what we have learned about ED crowding over the past 10 years. There exists quite a bit in the literature for those interested enough to read further. Of course at UL we don’t know much about ED crowding.
Hey this is not a case but what goes through my own head on a difficult shift. There is a lot of information out there on cognitive load / error. Dr Croskerry is essentially the EM world expert on this subject. Take a look at this most recent article. Another great resource are a couple books, one short and sweet the other very in depth. Both are dirt cheap now on Amazon.
Nice little post from EM Lit of Note on how to increase patient satisfaction scores. Hint, has nothing to do with quality medical care.
As customer satisfaction becomes rapidly enshrined as our reimbursement overlord, we are all eager to improve our satisfaction scores. And, by scores, I mean: Press Ganey.
So, as with all studies attempting to describe patient satisfaction, we unfortunately depend on the validity of the proprietary Press Ganey measurement instrument. This limitation acknowledged, these authors at Oregon Health and Science University have conducted a single-center study, retrospectively linking survey results with patient characteristics, and statistically evaluating associations using a linear mixed-effects model. They report three survey elements: overall experience, wait time before provider, and likelihood to recommend.
Which patients were most pleased with their experience? Old, white people who didn’t have to wait very long. Every additional decade in age increased satisfaction, every hour wait decreased satisfaction, and there was a smattering of other mixed effects based on payor source, ethnicity, and perceived length of stay. What’s interesting about these results – despite the threats to validity and limitations inherent to a retrospective study – is how much the satisfaction outcomes depend upon non-modifiable factors. You can actually purchase patient experience consulting from Press Ganey, and they’ll come teach you and your nurses a handful of repackaged common-sense tricks – but I’m happy to save your department the money: door-to-room times.
Or change your client mix.
Done.
“Associations Between Patient and Emergency Department Operational Characteristics and Patient Satisfaction Scores in an Adult Population”
http://www.ncbi.nlm.nih.gov/pubmed/25182541
Here’s an excerpt from our ED-Public Health website (http://www.edpublichealth.com):
ACEP’s contributions to the Choosing Wisely Campaign
At ACEP13 last October in Seattle, the organization announced its 5 contributions to the Choosing Wisely Campaign. Initially started by the American Board of Internal Medicine (ABIM) Foundation, the Choosing Wisely Campaign was a response to the movement towards improved healthcare efficiency and a need to decrease unnecessary/low-value procedures and tests. Despite ACEP’s original reluctance to join, in February 2013 ACEP jumped on board and began creating their list of recommendations. After extensive review by an expert panel of emergency physicians and the ACEP Board of Directors, ACEP’s Choosing Wisely recommendations were released.1,2 They include:
1. Avoid Head CTs in ED patients with minor head injury who are at low risk based on validated decision rules.
2. Avoid placing indwelling urinary catheters in the ED for either urine output monitoring in stable patients who can void, or for patient or staff convenience.
3. Don’t delay engaging available palliative and hospice care services in the ED for patients likely to benefit.
4. Avoid antibiotics and wound cultures in ED patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up.
5. Avoid instituting IV fluids before doing a trial of oral rehydration therapy in uncomplicated ED cases of mild or moderate dehydration in children.
You be the judge.
Here is a list of pros and cons formulated based on literature review, articles and editorials from other emergency physicians (EPs).
Pros:
1. Reduce cost without affecting quality of care.1,2
2. Improve efficiency.1,2 Example: shorter LOS if imaging is involved
3. Encourages shared decision-making between patients and physicians.1,2,8
4. Medical benefits: Less ionizing radiation exposure, less risk of antibiotic-resistant organisms, fewer catheter-associated UTIs.1,2,4
5. EP-generated, EP-approved. EPs are identifying “low value” procedures/tests for their own speciality, rather than letting others define these for us.1,2,6 For example: the proposed, but ultimately rejected, CMS “use of Brain CT in the ED for atraumatic headache” measure was created by CMS without EP input.8
Cons:
1. Lack of advocacy for medical liability reform.1,2,5
2. EPs have no right of refusal to our patients.5
3. EPs often pick up the slack for other doctors.5
4. Will it come to a point where these 5 tests/procedures will be uncompensated?5
5. Loss of autonomy.6
Other lists of over-used and “low value” tests exist out there. Most notable is a list of 5 tests which was created by EPs and mid-level providers from six Partners Healthcare hospitals near Boston. Published in JAMA, this list was designed to be “actions a specialty provider”7 can take.6,7 They include:
1. Do not order CT of the C-spine for patients after trauma who do not meet NEXUS low risk criteria or the Canadian C-spine Rule.
2. Do not order CT to diagnose PE without first risk stratifying for PE (pretest probability and D-dimer tests if low probability). (included in ACR’s Choosing Wisely list)3,4
3. Do not order MRI of the L-spine for patients with lower back pain without high-risk features. (included in AAFP’s and ACP’s Choosing Wisely list)3,4
4. Do not order CT of the Head for patients with mild traumatic head injury who do not meet New Orleans criteria and Canadian CT Head Rule.
5. Do not order coagulation studies on patients without hemorrhage or suspected coagulopathy (eg: with anticoagulation therapy, clinical coagulopathy)
ACR = American College of Radiology, AAFP = American Academy of Family Physicians, ACP = American College of Physicians
Bedside actions: to begin incorporating these EP-approved recommendations into our daily practice in an effort to institute cost-effective quality medical care (ideally before private insurers, CMS, or other specialty societies begin mandating us to do the same)
References:
1. ACEP Announces List of Tests as Part of Choosing Wisely Campaign. ACEP Clinical & Practice Management. October 14, 2013. Downloaded from http://www.acep.org/Clinical—Practice-Management/ACEP-Announces-List-of-Tests-As-Part-of-Choosing-Wisely-Campaign/.
2. ACEP Prepares List for Choosing Wisely Campaign. ACEP Clinical & Practice Management. Downloaded from http://www.acep.org/Clinical—Practice-Management/ACEP-Announces-List-of-Tests-As-Part-of-Choosing-Wisely-Campaign/.
3. Choosing Wisely Master List. www.choosingwisely.org. Downloaded from http://www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf.
4. Mahesh, M. and Durand, D.J. The Choosing Wisely Campaign and its Potential Impact on Diagnostic Radiation Burden. J Am Coll Radiol. 2013; 10(1): 65-6.
5. Seaberg, David. Pro/Con: Why ACEP Should Not Join the ‘Choosing Wisely’ Campaign. Emergency Physicians Monthly. Published August 24, 2012. Downloaded from http://www.epmonthly.com/features/current-features/the-wiser-choice-should-acep-join-the-choosing-wisely-campaign-no/.
6. Schuur, J.D., Carney, D.P., Lyn, E.T., Raja, A.S., Michael, J.A., Ross, N.G., and Venkatesh, A.K. A Top-Five List of Emergency Medicine: A pilot project to improve the value of emergency care. JAMA Intern Med. 2014; 174(4): 509-515.
7. The Tale of Two Lists: Procedures to Avoid in the ED. Acute Care, Inc. Published February 25, 2014. Downloaded from http://www.acutecare.com/the-tale-of-two-lists-procedures-to-avoid-in-the-ed.
8. Venkatesh, A.K. and Schuur, J.D. A “Top Five” list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care. American Journal of Emergency Medicine. 31 (2013) 1520-1524.
A frightening article about contract management groups and ED / Hospital staffing.
Hey guys a cool article from Dr Platt. Good perspective on our patients’ expectations.
Public health is associated with the least interesting courses of medical school (epidemiology and biostatistics). It has been linked to ED frequent flyers and psych hold patients (social and behavioral health). One might say it’s an integral part of vague clinical decision rules and flip-flopping society guidelines and Press-Ganey scores.
It’s also something us ED docs do every day, whether we want to or not. There’s no reason why we shouldn’t try to understand it and do it better.
Kiran and I have been developing a website dedicated to public health for ED personnel. It’s a FOAMed site. Our plan is to get it tied in with sites like EMCrit, ALiEM, LITFL, and the like. It’s still a very young project, but there’s a couple articles posted for you to glance at.
If anyone is interested in population health, there’s a ton of uncharted territory and we’d welcome the collaboration. Just let us know how you want to be involved. Also, tell your friends.
Hey Guys,
Thought I’d post this as I feel it was a mistake on my part, though fortunately no harm came from it.
50 year old guy this past Saturday (which was a ridiculous shift full of drunks and unhelmeted mopeds and motorcyclists with some very sick people) who was an unhelmeted moped rider going reportedly 60mph and wrecked while drinking alcohol and somehow managed not to make their way to Rm 9.
BP: 125/73. HR: 86. RR: 18. O2 saturation: 91% on room air. Temp: 97.6 F (oral)
A&Ox3, c/o shortness of breath and diffuse chest tenderness. Not really any obvious bad looking signs of trauma and had been log-rolled prior to my eval (triaged about 1hr 45min before I saw him).
I saw him, in no respiratory distress, maybe some expiratory wheezing on my exam, but with breath sounds on both sides and no crepitus that I could feel to his anterior chest. I finish my eval and just order a MAN scan based on his Hx and due to his drinking alcohol (EtOh 292)
Patient is taken to CT at 23:05 (about 2 hrs after I ordered them) and the nurse grabs me after the scan and tells me I need to look at his chest CT (only his C-spine images were up at the time which showed me all kinds of SubQ emphysema).
Just a lesson learned; when it’s super busy like that shift was is when we need to be the most cautious and really think critically about the things we need to do, and not be in a hurry when we’re putting orders in.
The guy is doing well so far (and not intubated) and in THIS case no harm was done, I put a chest tube in without difficulty. But I really should have gotten a CXR to start.
His injuries included Bilateral 1st-6th Rib Fx’s, Pulmonary Contusions, Mediastinal Hematoma, Manubrium Fx, C7 Fx, T4, T7 Fx.
Interesting article by a retired academic physician / “business executive.”
I love these articles that scare the crap out of me. Took some navigating to get this pdf and it looks like the unofficial manuscript. Saw it on EM Lit of Note. Another good one of his was the EMR exposing one. 28% patient care, 44% data entry. We are drones.