UMEM Educational Pearls - Administration

OTC Medication and Concussion Recovery

A recent cohort study performed by the NCAA and US Department of Defense looked at NCAA athletes and military cadets who had suffered a concussion.

The study included 1661 NCAA athletes and military cadets, mean age was about 18 years, and 45% were women.

In these groupings, 813 people took over-the-counter pain relievers after their concussion and 848 people did not take any pain relievers.

Analgesics used included medications such as acetaminophen or NSAIDs such as ibuprofen.

Acetaminophen (n = 600), NSAIDs (n = 75), and those taking both (n = 78).

Outcomes: Time to clearance for activity without restrictions

 1)  50% recovery

  1. 90% recovery

Results:

  1. There was no difference between the type of pain reliever taken and recovery
  2. Patients who took OTC analgesics had lower symptom severity scores
  3. Patients who took OTC analgesics were cleared at 50% recovery  two days faster, and at 90% recovery seven days faster than those who took no medication.
  4. Those who initiated OTC analgesics on the first day of injury returned to play and had resolution of symptoms approximately eight days faster than those who started taking medication after five or more days.

Conclusion: Consider early initiation of OTC analgesics in concussed patients at time of discharge.

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Title: Team Dynamics in Emergency Medicine

Category: Administration

Keywords: Team building, belonging, team dynamics, emergency physicians, emergency nurses (PubMed Search)

Posted: 3/25/2025 by Mercedes Torres, MD (Updated: 3/26/2025)
Click here to contact Mercedes Torres, MD

Better teamwork creates better outcomes in emergency medicine. This study investigated how communication practices between physicians and nurses in the ED influence team dynamics and the sense of belonging to the healthcare team.

Methods: 38 emergency physicians and emergency nurses from EDs within a single metropolitan area participated in focus groups.

Positive Influences on Team Belonging:

  1. Proactivity and anticipating needs: Physicians specifically demonstrated proactivity by “talking to the triage (nurse), talking to the charge (nurse) about what is it that I can be doing to help.” Nursing identified anticipating the physician’s equipment and workflow needs as a helpful anticipatory task.
  2. Projecting openness: Projecting openness through verbal or nonverbal techniques was associated with more open lines of communication and improved team dynamics. For example, asking the team “what are we missing?” to invite input from all team members on the care plan.
  3. Less formal name conventions: Knowing and calling each other by first names increased healthy relationships among team members, especially between physician and nurses.
  4. Building relationships outside of work: Establishing a relationship and getting to know a team member was described as helpful when subsequent brisk professional communication is required, such as during the care of a critically ill patient.

Negative Influences on Team Belonging:

  1. Giving up on or resisting communication  
  2. Dismissal of ideas from nursing
  3. Suggestions of laziness with regards to team members

The findings emphasize the importance of fostering positive communication practices to enhance team dynamics, cohesiveness, and overall well-being within ED healthcare teams.

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Title: Patient care for Muslim patients during Ramadan

Category: Administration

Keywords: Ramadan, fasting, DEI (PubMed Search)

Posted: 3/15/2025 by Hanna Hussein, MD (Updated: 3/31/2025)
Click here to contact Hanna Hussein, MD

Ramadan is the holy month in the Islam faith, where observers will fast from sunrise to sunset.  This includes food, water, some medications, smoking and sex.  This can obviously have some impact on patients' health, especially when presenting to the ED.  Here are some considerations to keep in mind:

  • In general, there are exemptions to fasting for pregnant persons, children,  breastfeeding persons, and people travelling. 
  • Bleeding is considered a contraindication to fasting, so menstruating women are exempt.  Some people may interpret this to mean they cannot give blood or have lab work done, but there is an exemption for medical purposes
  • Volume status is probably the main area to be concerned about.  Always ask your patients if they are currently fasting and explain why IV fluids would be necessary

As with everything, maintaining cultural awareness and compassion will help to

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Title: Attrition among Nurse Practitioners and Physician Assistants in Emergency Medicine

Category: Administration

Keywords: Nurse Practitioner, Physician Assistant, job satisfaction, burnout, longevity (PubMed Search)

Posted: 2/20/2025 by Steve Schenkel, MPP, MD (Updated: 2/26/2025)
Click here to contact Steve Schenkel, MPP, MD

Nurse Practitioners and Physician Assistants practice alongside Physicians in Emergency Departments. In 2021, an estimated 17,679 NPs and PAs worked in EDs.

How long do NPs and PAs continue in Emergency Medicine practice?

An analysis of Medicare data reports that over the eight years of the study, the annual attrition rate averaged 13.8%, or almost 1 in 7 leaving Emergency Medicine practice every year. At the time of attrition, the median age for women was 40.2 years (IQR 33.8 to 49.9) and for men was 45.9 (IQR 37.8 to 56.3).

For additional breakdown and discussion of these numbers, see Gettel CJ, Chosh R, Rothenberg, et al. Workforce Attrition Among Emergency Medicine Non-Physician Practitioners. Ann Emerg Med, in press, https://www.annemergmed.com/article/S0196-0644(24)01294-0/fulltext.



Diversity, Equity and Inclusion is more than just a collection of buzzwords or political noise.  They are real, important and necessary components to provided excellent, compassionate and culturally appropriate care to all of our patients.  EDs across the country are looking for ways to incorporate the principles of diversity, equity and inclusion.  To do this effectively needs both a bottom-up and top-down approach.

This study details the results of a top-down approach to incorporate diversity, equity and inclusion at a very large ED system.  Leaders on every level of their organization participated in book clubs followed by a guided discussion of one of 9 themes- examination of privilege, initial reaction to discussion about racism, discomfort, worry, self-reflection, release, role recognition, readiness, and education.

The results showed that all participants were able to move from a feeling of paralysis due to the enormity of the challenges and defensiveness, to a release of that paralysis with a commitment to move the organization forward in a positive way.

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Title: Promoting Wellbeing Among the Physician Workforce

Category: Administration

Keywords: Burnout, Wellbeing, Workforce (PubMed Search)

Posted: 1/22/2025 by Mercedes Torres, MD (Updated: 3/31/2025)
Click here to contact Mercedes Torres, MD

On March 18, 2022, Congress passed the Dr. Lorna Breen Health Care Provider Protection Act, named after an emergency medicine physician who died by suicide during the pandemic. This landmark legislation allocated $103 million across 45 organizations to introduce evidence-based measures to mitigate and prevent burnout.

As a result, the Impact Wellbeing Guide was developed, outlining the six key evidence-based action steps for organization leaders to address health care workers’ professional well-being listed below:

  1. Conduct a review of your hospital’s operations to determine how they support professional wellbeing.
  2. Build a dedicated team to support professional wellbeing at your hospital.
  3. Break down barriers to seeking help, such as updating and removing intrusive mental health questions on credentialing applications and offering confidential mental health support options.
  4. Develop a suite of communication tools that help you share updates with your workforce about your hospital’s journey to improve professional wellbeing.
  5. Integrate professional wellbeing into an existing quality improvement project at your hospital.
  6. Create a 12-month plan to continue to move your workforce’s professional wellbeing work forward.

The Guide is designed to help hospital leaders and executives accelerate or supplement professional wellbeing work in their hospitals at the operational level.

A PDF of the full guide is available from the CDC: https://www.cdc.gov/niosh/docs/2024-109/

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Title: Can interruptions be helpful?

Category: Administration

Keywords: push notification, EMR, ED flow, results, radiology (PubMed Search)

Posted: 12/26/2024 by Steve Schenkel, MPP, MD (Updated: 3/31/2025)
Click here to contact Steve Schenkel, MPP, MD

Clinical practice in the world of the Electronic Medical Record has made many a clinician question the value of electronic reminders. 

Banners warn of sepsis, the need for repeat evaluation, vital signs outside expected limits,  wait times, and risks for readmission.

Can they instead help ED flow?

Sayan Dutta and colleagues suggest that they can. When clinicians chose to receive notice of a lab or imaging result, push notification reduced time between final result and ED disposition by 18 minutes (95% CI: 15-21 minutes). 

The likely key here? Clinicians actively chose when and about what to be notified.

See: Result Push Notifications Improve Time to Emergency Department Disposition: A Pragmatic Observational Study, Annals of Emergency Medicine, 85(1), 53-62. https://www.annemergmed.com/article/S0196-0644(24)00404-9/abstract.

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Title: Happy Thanksgiving!

Category: Administration

Keywords: Thanksgiving (PubMed Search)

Posted: 11/27/2024 by Robert Flint, MD (Updated: 3/31/2025)
Click here to contact Robert Flint, MD

From all of us at UMEM, Happy Thanksgiving!!
We are incredibly Thankful for each of you and all that you do to care for patients and their families. 
We are Thankful for those legends who have blazed the path in EM like Greg Henry who the EM community lost yesterday. Our thoughts are with his family. Thank you Dr. Henry for inspiring so many of us. Our pearls today  are two of  his famous quotes:

“Medicine is show business for ugly people.”

“You don’t go to Disney and see Mickey taking a smoke break. You have to be on when you are on shift”



Title: AI and EM

Category: Administration

Keywords: artificial intelligence, emergency department, emergency practice, machine learning (PubMed Search)

Posted: 11/27/2024 by Mercedes Torres, MD
Click here to contact Mercedes Torres, MD

Gooble, gooble,… gulp, some food for thought on the eve of Thanksgiving.

The development of artificial intelligence (AI) in emergency medicine is well under way.  The schematic below and accompanying reference presents the anticipated stages in the process of AI development, including important features, considerations, and challenges as we move towards increased integration of AI in our practice of EM.

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Title: Does physician altruism influence quality metrics?

Category: Administration

Keywords: physician practice, morality, altruism, professionalism (PubMed Search)

Posted: 10/17/2024 by Steve Schenkel, MPP, MD (Updated: 10/23/2024)
Click here to contact Steve Schenkel, MPP, MD

Does physician altruism influence quality metrics? This study suggests yes.

45 physicians were defined as “altruistic” based on their willingness to share a $250 cash prize with a stranger in an on-line version of the dictator game, something you might have played in an economics class.

Of 250 physicians drawn from primary care and cardiology, 45 met the definition of altruistic and 205 did not. 

Overall, patients of altruistic physicians:

  • Were less likely to experience ambulatory care sensitive admissions (absolute decrease of 1%, relative decrease of 38%, adjusted odds ratio 0.6 (0.38-0.97))
  • Were less likely to experience ambulatory care sensitive emergency department visits (absolute decrease of 1.5%, relative decrease of 41%, adjusted odds ratio 0.64 (0.43-0.94)
  • Had lower total spending (adjusted decrease of $800, relative change of -9.3% (16.2-2.3). [Note: the unadjusted results run in the other direction.]

The authors suggest that this difference may be on account of altruistic physicians being more willing to consider the appropriateness of tests or treatment or “devote more time and energy to their patients.”

They also note that while most physicians were categorized as not altruistic, at 18% this group of physicians exceeds the 5% of the general US population that would meet this definition. 

Perhaps there is something quantitatively demonstrable to being a “good” doctor.

See https://jamanetwork.com/journals/jama-health-forum/fullarticle/2824419

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Title: How does our workspace effect our work?

Category: Administration

Keywords: design, workspace, handoff, interruptions, collaboration (PubMed Search)

Posted: 9/21/2024 by Mercedes Torres, MD (Updated: 9/25/2024)
Click here to contact Mercedes Torres, MD

  • Did you know that emergency physicians spend nearly 1/3 of their handoff time responding to interruptions?
  • EPs are interrupted around 7-11 times during handoffs, accounting for 11% of the total adverse events, a third of which are considered preventable.
  • This study examined the number of interruptions and perception of collaboration in three different physical spaces in the same ED: an open workstation, an enclosed workstation, and a semi-open workstation (see photos and blueprints below).
  • Most EDs have open workstations as they are thought to optimize visibility and opportunities for collaboration among team members of all levels.
  • EPs conducting handoffs in open workstations experienced more interruptions (patient care-related or not) as compared to those in the enclosed workstations. 
  • Investigators found that enclosure of the physicians’ workstation can decrease the number of times physicians are interrupted during critical tasks like handoffs, therefore decreasing the risk of errors and adverse events.
  • EPs perceived a high degree of collaboration with colleagues in the enclosed workstation during handoff and felt less interrupted.
  • While the number of documented handoff interruptions in the semi-open plan were lower than the open workstation, EPs still perceived interruptions as frequent. 
  • While there are clear benefits of the open workstation in the ED, it may be worth considering a different venue, specifically for handoffs, such as a “No Interruptions Zone” (NIZ) to decrease the perceived and actual frequency of interruptions, while also improving the sense of collaboration between team members during the handoff process.

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Title: Medicare is Changing

Category: Administration

Keywords: Medicare advantage, insurance, payor, fee-for-service (PubMed Search)

Posted: 8/28/2024 by Steve Schenkel, MPP, MD (Updated: 3/31/2025)
Click here to contact Steve Schenkel, MPP, MD

Traditional Medicare now covers < 50% of Medicare beneficiaries. It reimburses on a fee-for-service basis. For beneficiaries, it includes deductibles and coinsurance requirements that yield average annual out-of-pocket expenses measured in the thousands of dollars.

Medicare Advantage, the new alternative, has grown quickly. Plans typically promise beneficiaries fewer co-pays and more services. It relies on private insurers (think United, Blue Cross, Kaiser Permanente) to coordinate care and rein in costs. Subsidies to Medicare Advantage have helped spur growth, subsidies that mean costs per beneficiary for Medicare Advantage exceed those for traditional Medicare.

Which means Medicare still needs to figure out how to save money and remain viable while the US population over 65 grows.

When listening to a lecture about Medicare or reading a study that uses Medicare data, take a moment to ask “Which Medicare? Fee-for-service? Or Advantage?”

For a take on the future of Medicare, see McWilliams JM, The Future of Medicare and the Role of Traditional Medicare as Competitor, NEJM, August 22/29, 763-769.

To understand why Medicare Advantage plans are popular, see https://www.kff.org/medicare/issue-brief/10-reasons-why-medicare-advantage-enrollment-is-growing-and-why-it-matters/.

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Title: Research - Confounding Variables

Category: Administration

Keywords: confounding factors, epidemiologic (PubMed Search)

Posted: 8/21/2024 by Mike Witting, MS, MD
Click here to contact Mike Witting, MS, MD

“I’m not going to the hospital, my father died in a hospital.”

In planning a study it’s a good practice to consider what confounding variables you may need to look out for.

Confounding variables are associated with the predictor (independent) and outcome (dependent) variables, but they are not in the causal chain. In the above example, disease is likely the predictor variable, death is the outcome variable, and going to the hospital is a confounder. Of course, this assumes the death was not iatrogenic; then the hospital would be in the causal chain.

Patients may be selected for interventions based on severity of disease, functional status, education level, and other factors, and these may be confounders.

Confounding can be addressed at the design stage, by:

  • Specification – excluding patients with the confounder (often not feasible)
  • Matching – selecting cases and controls matched by confounding variable levels
  • Randomization – randomly select patients for an intervention and hope confounding variables will balance out

It can be addressed in the analysis stage by:

  • Stratification – analyzing data in strata defined by confounding variable levels
  • Adjustment – mathematically adjusting for the confounding variable (usually by regression)

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This retrospective study found that while overall rates of antibiotic prescriptions for viral URIs were low (that's good!), patients identified as non Hispanic white were prescribed antibiotics, despite guidelines advising against them,  at a higher rate than non white patients (that's bad).  It also found that in areas of socioeconomic deprivation, the prescribing rates were lower across all races than in more affluent areas (that's good and bad!)

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Title: Meetings: Finding the Right Balance

Category: Administration

Keywords: Administration, Meetings, Workforce satisfaction (PubMed Search)

Posted: 7/24/2024 by Mercedes Torres, MD
Click here to contact Mercedes Torres, MD

Participation in meetings is an expected part of most (if not all) of our jobs.  How many of these meetings are necessary?  Could some of the “work” of meetings be accomplished with a few emails or other asynchronous forms of communication?  Are meetings cluttering your schedule and making it impossible to get any real work done?

Some answers to these questions are offered in a Harvard Business Review article from March 2022.  

Key points include:

  • 70% of all meetings keep employees from working and completing all their tasks.
  • Ineffective meetings that waste our time can negatively impact psychological, physical, and mental wellbeing.

Advantages to fewer meetings:

  • Productivity was 71% higher when meetings were reduced by 40%.
  • Employees feel empowered and more autonomous, increasing their job satisfaction by 52%.
  • Removing 60% of meetings increased cooperation by 55%.

Authors recommend holding meetings only when “absolutely” necessary. That typically includes:

  • To review work that’s occurred (what worked or didn’t and why)
  • To clarify and validate something (policies, team goals, etc.)
  • To distribute work appropriately among your team

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Title: Can EMS safely give antibiotics for isolated open extremity fractures?

Category: Administration

Keywords: osteomyelitis, antibiotics, golden hour, trauma, open fracture (PubMed Search)

Posted: 7/17/2024 by Jenny Guyther, MD (Updated: 3/31/2025)
Click here to contact Jenny Guyther, MD

Early administration of antibiotics for open fractures can reduce serious bone and soft tissue infections, with a common goal being antibiotic administration within one hour of injury.

In this study, there were 523 patients treated by EMS who had an open extremity fracture.

The median time from EMS dispatch until antibiotic administration was 31 minutes.  99% of the patients who received antibiotics received them within one hour of EMS dispatch.  Prehospital times were on average 10 minutes longer for those patients who received antibiotics.  The majority of these patients received cefazolin, followed by ceftriaxone, ampicillin, gentamicin and piperacillin/tazobactam.  None of these patients required management for an allergic reaction or anaphylaxis.  Five patients (1%) who received prehospital antibiotics and 159 patients who did not (1.4%) had a subsequent infection based on ICD codes.

Bottom line: In this small group, it was safe to administer antibiotics to a patient with an isolated open extremity fracture and the medication was able to be delivered earlier.  Larger studies will be needed to see the impact of this practice on the development of osteomyelitis or soft tissue infections.

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Title: What is Administrative Harm?

Category: Administration

Keywords: administrative harm, employee, adverse events (PubMed Search)

Posted: 6/26/2024 by Steve Schenkel, MPP, MD (Updated: 3/31/2025)
Click here to contact Steve Schenkel, MPP, MD

“Administrative harm” (defined as “the adverse consequences of administrative decisions within health care”) is a relatively new term for challenges that arise in complex health care work environments. 

41 mostly hospitalists participating in interviews and focus groups found that the concept resonated, and that administrative harms could arise at all levels of leadership, negatively impacted both workforce and patients, were challenging to measure, and pointed to a lack of leadership responsibility and accountability. The group also suggested many approaches and solutions for prevention.

The article is here, https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2820266. If interested, take a look at the thematic tables 2 and 3.

There is a brief editorial comment here, https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2820275.



Title: STI Prophylaxis

Category: Administration

Keywords: STI, prophylaxis (PubMed Search)

Posted: 6/24/2024 by Visiting Speaker (Updated: 3/31/2025)
Click here to contact Visiting Speaker

Author:

Gabriella Miller (She/Her)

Clinical Instructor

Department of Emergency Medicine

University of Maryland School of Medicine

Doxycycline PEP for the prevention of bacterial STIs.

The CDC now recommends “doxy PEP” for high-risk individuals. Doxycycline post-exposure prophylaxis (doxy PEP) is a prescription for patients to self-administer 200 mg doxycycline by mouth within 72 hours after anal, oral, or vaginal sex to prevent the transmission of chlamydia, gonorrhea, and syphilis. The CDC defines “high-risk” as men who have sex with men (MSM) and transgender women (TGW) who have been diagnosed with a bacterial STI within the past 12 months. They summarize the findings of the French IPERGAY and ANRS DOXYVAC studies, as well as the US DoxyPEP study, which all show promising reductions in risk ratios or hazard ratios of decreasing bacterial STI transmission on high-risk populations, including those who are taking PrEP for HIV. No significant adverse events related to doxy PEP have been reported.

Conclusion:

Counsel patients at high risk for bacterial STIs regarding the prescription of doxy-PEP for patient self-administration within 72 hours after sex.

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Title: Pulse Oximetry's Color Bias

Category: Administration

Keywords: pulse oximetry, skin pigmentations (PubMed Search)

Posted: 6/15/2024 by Kevin Semelrath, MD (Updated: 3/31/2025)
Click here to contact Kevin Semelrath, MD

This article shows us that even things we think of as objective measures in medicine may actually perpetuate systemic biases.  

The study evaluated controlled hypoxemia in a group of volunteers.  Traditional pulse ox devices measured falsely elevated pulse ox readings in participants with dark skin pigmentation and low tissue perfusion.  It suggested different types of devices that may have improved accuracy in patients with darker skin pigmentation, but the underlying problem still exists.

Bottom line, this goes to prove what we have taught, never rely on a single value to reassure yourself of the patient's status, always take into account the bigger picture.

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Title: Water Baths for Fingers

Category: Administration

Keywords: POCUS, musculoskeletal, fingers, water baths (PubMed Search)

Posted: 6/3/2024 by Alexis Salerno, MD (Updated: 3/31/2025)
Click here to contact Alexis Salerno, MD

Do you have a patient with a finger injury or infection, or possibly a retained foreign body?

Try placing the hand in a water bath and use a linear ultrasound probe for evaluation. If there is an open wound, use a sterile ultrasound probe cover.

With ultrasound guidance, you can observe dynamic finger movements and identify areas that may require abscess drainage.