Category: Administration
Keywords: Thanksgiving (PubMed Search)
Posted: 11/27/2024 by Robert Flint, MD
(Updated: 12/12/2024)
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”
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.
Petrella, R. The AI Future of Emergency Medicine. Ann Emerg Med. 2024;84:139-153. https://doi.org/10.1016/j.annemergmed.2024.01.031
Category: Administration
Keywords: DEI, clinical decision tools, renal colic (PubMed Search)
Posted: 11/14/2024 by Kevin Semelrath, MD
(Updated: 11/16/2024)
Click here to contact Kevin Semelrath, MD
You know we all love our clinical prediciton rules! But we also know that many of them include race as a predictive factor that probably does not have a basis in actual human physiology.
These authors looked at the STONE score (a new one to me!) that looked to predict the presence of uncomplicated renal stones as the source of “renal colic pain” and also rule out some of the more serious mimics. The original score included origin, defined as non-Black race, as one of the predictors of stone disease. The study authors revalidated the score substituting obvious, or visible, hematuria for origin and found no difference in clinical accuracy.
When using these kind of tools, this study re-emphasizes the need to scrutinize the inclusion of race based inclusion or exclusion criteria, and whether they are based on any actual evidence.
Christopher L. Moore MD, Cary P. Gross MD, Louis Hart MD, Annette M. Molinaro PhD, Deborah Rhodes MD, Dinesh Singh MD, Cristiana Baloescu MD
First published: 07 November 2024
https://doi.org/10.1002/emp2.13324
Supervising Editor: Yiju Teresa Liu, MD and Henry Wang, MD, MS
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:
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
Casalino LP, Kariv S, Markovits D, Fisman R, Li J. Physician Altruism and Spending, Hospital Admissions, and Emergency Department Visits. JAMA Health Forum. 2024;5(10):e243383. doi:10.1001/jamahealthforum.2024.3383
Category: Administration
Keywords: SOGI, sex, gender (PubMed Search)
Posted: 10/19/2024 by Kevin Semelrath, MD
(Updated: 12/12/2024)
Click here to contact Kevin Semelrath, MD
These authors looked at reported demographics, specifically focusing on sex and gender reporting, from studies in a number of high profile, multi-disciplinary fields.
They found that often only sex- referring biological sex assigned at birth- was reported. They found that the terms male/female as opposed to man/woman were the primary designations used, and a vast majority of studies and journals significantly underreported transgender, intersex and nonbinary demographics.
This study reinforces the need for more accurate reporting of SOGi data in research studies, to improve the equity of this patient population in up and coming research
Michael Gottlieb MD, Rachel Chang, Miranda Viars, Alexandra Mannix MD
First published: 17 February 2024
https://doi.org/10.1111/acem.14866
Supervising Editor: Jody Vogel
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
Joshi R, Joseph A, Ossmann M, et al. Emergency Physicians’ Workstation Design: An Observational Study of Interruptions and Perception of Collaboration During Shift-End Handoffs. HERD: Health Environments Research & Design Journal. 2021;14(4):174-193. doi:10.1177/19375867211001379
Category: Administration
Keywords: DEI, Latinx (PubMed Search)
Posted: 8/31/2024 by Kevin Semelrath, MD
(Updated: 9/21/2024)
Click here to contact Kevin Semelrath, MD
The term Latinx gained some popularity as a gender neutral/noncomforming descriptor for people of Hispanic descent. However, in some national surveys among Hispanic populations in the US, only a small percent were even aware of the term or what it meant.
This study looked at patients at several hospitals with large Hispanic populations. Again a minority of respondents had even heard of the term. In those that had heard of it, there were a wide range of self reports interpretations of what exactly it means.
In the end, we come back to the same conclusion: if you want to know how your patient wants to be addressed, just ask. Don't assume
Molina, Melanie F. et al.
Annals of Emergency Medicine, Volume 0, Issue 0
Category: Administration
Keywords: Medicare advantage, insurance, payor, fee-for-service (PubMed Search)
Posted: 8/28/2024 by Steve Schenkel, MPP, MD
(Updated: 12/12/2024)
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/.
Category: Administration
Keywords: confounding factors, epidemiologic (PubMed Search)
Posted: 8/21/2024 by Mike Witting, MD
Click here to contact Mike Witting, 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:
It can be addressed in the analysis stage by:
Adapted from Hulley SB, Cummings SR. Designing clinical research, 4th edition, Lippincott, Williams and Wilkins, 2013.
Category: Administration
Keywords: racial disparities, antibiotic prescribing (PubMed Search)
Posted: 8/14/2024 by Kevin Semelrath, MD
(Updated: 8/17/2024)
Click here to contact Kevin Semelrath, MD
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!)
Open AccessPublished:January 23, 2024DOI:https://doi.org/10.1016/j.annemergmed.2023.12.003
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:
Advantages to fewer meetings:
Authors recommend holding meetings only when “absolutely” necessary. That typically includes:
Laker B, Pereira V, Malik A, and Soga L. Meeting Management: Dear Manager, You’re Holding Too Many Meetings. Harvard Business Review. March 9, 2022.
Category: Administration
Keywords: osteomyelitis, antibiotics, golden hour, trauma, open fracture (PubMed Search)
Posted: 7/17/2024 by Jenny Guyther, MD
(Updated: 12/12/2024)
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.
Muniz AD, Gregorio DJ, Studebaker SA, et al. Time Savings and Safety of EMS Administration of Antibiotics for Open Fractures. Prehosp Emerg Care. Published online April 25, 2024. doi:10.1080/10903127.2024.2347291
Category: Administration
Keywords: administrative harm, employee, adverse events (PubMed Search)
Posted: 6/26/2024 by Steve Schenkel, MPP, MD
(Updated: 12/12/2024)
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.
Category: Administration
Keywords: STI, prophylaxis (PubMed Search)
Posted: 6/24/2024 by Visiting Speaker
(Updated: 12/12/2024)
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.
Bachmann LH, Barbee LA, Chan P, et al. CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024. MMWR Recomm Rep. 2024;73(2):1-8. Published 2024 Jun 6. doi:10.15585/mmwr.rr7302a1
Category: Administration
Keywords: pulse oximetry, skin pigmentations (PubMed Search)
Posted: 6/15/2024 by Kevin Semelrath, MD
(Updated: 12/12/2024)
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.
Low Perfusion and Missed Diagnosis of Hypoxemia by Pulse Oximetry in Darkly Pigmented Skin: A Prospective Study. Anesth Analg. 2024 Mar 1;138(3):552-561. doi: 10.1213/ANE.0000000000006755. Epub 2023 Dec 18. PMID: 38109495
Category: Administration
Keywords: POCUS, musculoskeletal, fingers, water baths (PubMed Search)
Posted: 6/3/2024 by Alexis Salerno, MD
(Updated: 12/12/2024)
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.
Category: Administration
Keywords: Specialty ED, Geriatric ED, Oncologic ED (PubMed Search)
Posted: 5/21/2024 by Mercedes Torres, MD
(Updated: 5/22/2024)
Click here to contact Mercedes Torres, MD
There is a growing trend toward the development of specialty-specific emergency services, such as Geriatric or Oncologic EDs.
Will this trend continue? Is the segmentation of emergency care in our future? The author of this article opines that the answer depends on future outcomes research in this area.
Brouillette M. Are Specialty Emergency Departments the Future of Emergency Care? Oncology- and Geriatric-Focused Emergency Departments Hope to Improve Care, Lower Costs. Annals of Emergency Medicine. May 2024, 83(5):9A-12A. https://doi.org/10.1016/j.annemergmed.2024.03.015
Category: Administration
Posted: 5/13/2024 by Robert Flint, MD
(Updated: 12/12/2024)
Click here to contact Robert Flint, MD
This retrospective study looked at patients diagnosed with urinary tract infections receiving an IV dose of antibiotics prior to discharge and compared ED length of stay and return visit rate. They found:
“Parenteral antibiotic administration in the ED was associated with a 60-minute increase in ED LOS compared with those who received an oral antibiotic (P < 0.001) and a 30-minute increase in ED LOS compared with no antibiotic (P < 0.001). No differences were observed in revisits to the ED at 72 hours”
Appears no benefit to the practice of IV antibiotics prior to discharge in UTI patients.
Mohammed A. Alrashed Stephen J. Perona Mark C. Borgstrom Elias Ramirez-Moreno
JAPhA VOLUME 64, ISSUE 3, 102020, MAY 2024
Published:January 29, 2024DOI:https://doi.org/10.1016/j.japh.2024.01.016
Category: Administration
Keywords: trauma, EMS, hemorrhagic shock (PubMed Search)
Posted: 5/3/2024 by Ben Lawner, MS, DO
Click here to contact Ben Lawner, MS, DO
BACKGROUND:
Prehospital administration of whole blood involves some areas of controversy. Though theoretical benefits are clear, concerns about logistics and timing of blood often dominates the discussion. This study was a retrospective analysis of prehospital blood administration within an urban EMS system from 2021-2023. Primary endpoints included: time to administration and in hospital mortality.
PATIENTS/METHODS:
The study population included patients presenting to the EMS system with signs and symptoms of hemorrhagic shock (SBP<70 or SBP<90 + HR> 100, n=61) and who received at least 1 unit of prehospital blood (PHB). The EMS system administered blood in conjunction with an advanced resuscitative bundle (calcium, TXA, blood). Isolated head injuries and blunt trauma patients were excluded from the analysis. The control group (n=82) was comprised of patients in the system's trauma registry presenting to EMS PRIOR to the initiation of whole blood and who exhibited similar clinical crtieria.
RESULTS:
BOTTOM LINE:
In this prospective study conducted within an urban EMS system, patients receiving prehospital whole blood demonstrated improved vital signs and reduced mortality when compared to a control group. Slightly extended prehospital time intervals for patients receiving PHB may be offset by the measured benefits of whole blood therapy.
Duchesne, J. , McLafferty, B. , Broome, J. , Caputo, S. , Ritondale, J. , Tatum, D. , Taghavi, S. , Jackson-Weaver, O. , Tran, S. , McGrew, P. , Harrell, K. , Smith, A. , Nichols, E. , Dransfield, T. , Marino, M. & Piehl, M. (9900). Every minute matters: Improving outcomes for penetrating trauma through prehospital advanced resuscitative care. Journal of Trauma and Acute Care Surgery, Publish Ahead of Print , doi: 10.1097/TA.0000000000004363.
Category: Administration
Keywords: staffing, employment, Teamhealth, Medstar, Edelman (PubMed Search)
Posted: 3/16/2024 by Steve Schenkel, MPP, MD
(Updated: 4/17/2024)
Click here to contact Steve Schenkel, MPP, MD
Emergency Medicine staffing groups can be organized in any number of ways. Here’s Leon Adelman’s take:
Read more at https://emworkforce.substack.com/p/state-of-the-us-emergency-medicine-677. Read closely and you’ll find a reference to Maryland.