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.
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.
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.
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.
Do microaggressions and discrimination impact the patient experience in your ED? How can we address this?
This article is one of few studies to address this topic specifically in the ED. Authors used quantitative (discrimination scale) and qualitative (follow-up interviews) methods to answer this question in two urban academic EDs.
Common themes from patient responses provide food for thought and action in this regard:
This study is out of the American University of Beirut, Lebanon, and courtesy of our own Mazen El Sayed!
Many patients of Muslim faith will observe fasting during the month of Ramadan, with no food, water, oral of IV medication taken from sunrise to sunset
This study showed a lower daily ED volume than during non Ramadan months, however did show a higher length of stay during Ramadan.
It also found an increase in mortality rates during Ramadan (OR 2.88) and 72 hour ED bounce-backs (OR 1.34)
Be sensitive and aware of the needs of your patients of Muslim faith during this holy month of fasting.
Ramadan Kareem
The relationship between an Emergency Physician and the hiring group (whether large or small) may be one of employer-employee or contactor-independent contractor. There are legal job protections for employees that don’t exist for independent contractors. There are also regulations that define an independent contractor. Enforcement of these regulations varies but may be increasing. This has implications for the Emergency Medicine job market. We have the highest percentage of independent contractors of any medical specialty.
See more at Leon Adelman’s Emergency Medicine Workforce Newsletter, here https://emworkforce.substack.com/p/thousands-of-employed-emergency-physicians
This research letter notes: “The Rural Emergency Hospital is a new Medicare payment model available to hospitals with 50 or fewer beds in rural areas. Rural hospitals converting to this model will have emergency department (ED), observation, and outpatient services.”. Their study concludes that the majority of these hospitals already transfer the vast majority of their admissions to larger hospitals and this designation is a recognition of already established practices.
These authors performed a scoping review of English language studies involving United States general surgery patients that required transfer to another facility looking at timing of transfer, triage guidelines, and mode of transport . They concluded: “There were mixed results for the impact of transfer timing on outcomes with heterogeneous definitions of delay and populations. Triage guidelines for EGS transfer were consensus or expert opinion. No studies were identified addressing the mode of interfacility EGS transfer.” More research is needed in the area concerning timing, triage and mode of transport for these patients.
Approximately half of all Medicare beneficiaries are now enrolled in Medicare Advantage plans. Why does this matter?
Intrigued? Learn more at https://www.nejm.org/doi/full/10.1056/NEJMhpr2302315 or https://www.kff.org/medicare/issue-brief/medicare-advantage-2024-spotlight-first-look/.
From the Canadian Medical Protective Association looking at 5 years of closed medical legal cases. This fits with previous risk management data and should give us pause when treating these conditions.
This study was a retrospective review of restraint use at a level 1 trauma center in the Midwest.
It found the following were factors in a patient encounter associated with an increased risk of restraint usage:
This study found a decreased OR of restraint use with Black or Hispanic race, which was in contrast to other studies
This was a single center, retrospective study, so it was already limited in what it could tell us. In addition, they didn't see the reason for the restraints being ordered in the first place. Nonetheless, it does show that people in certain marginalized groups have a higher likelihood of ending up in restraints. Please think twice when ordering restraints in the ED, especially for behavioral reasons
Since 2014, Medicare has payed for inpatient services for Medicare patients who’s admitting physician noted that hospital stay required at least 48 hours (measured as 2 midnights) or required specialty care that could not be performed as an out patient. This rule now will apply to Medicare Advantage insurance patients as well. Physicians will need to document their reasoning why a patient’s stay will likely require two midnights.
As the calendar flips to a new year, consider not setting goals or resolutions. Studies show unmet goals or having too many half finished projects leads to increased stress, anxiety and depression. Instead, consider approaching the new year looking for growth, introspection, and striving to achieve excellence. Understanding the why and what motivates you will lead to the correct what and how. Here are some questions to get you thinking about the why. May your New Year be filled with growth and excellence!
A recently published study of ED APPs, residents, attendings, and nurses attempted to assess clinician's perspectives on how ED boarding impacts ED staff and patients. Authors performed a survey followed by focus group sessions to obtain qualitative insignts from participants.
All respondents associated boarding with feelings of burnout and self-reported poor satisfaction with communication and the process of boarding care.
Several key themes emerged which are outlined below:
This publication highlights the negative workforce and patient safety effects of ED boarding. It amplifies the voices of our colleagues who work towards change to improve both the health of our wrokforce as well as that of our patients and the communities that we serve.
Takeaway Points - A 10 percent reduction in ED volume reduces an ED patient's chance of dying by 24% at 30 days and by 17% at six months
The author of this study conducted a unique natural experiment. They identified cases in which a new emergency department opened near one or more existing departments. Then, they confirmed that the opening of the new department was the only substantial change that occurred (e.g. the staff in the existing EDs were unchanged, the types of complaints were unchanged etc.). The author then determined the impact of the new ED on the existing ED's patient volume and compared death records from the existing EDs before and after the new ED opened.
Simply offloading 10 percent of patients from the existing ED to the new ED, significantly reduced the 30 day and six month risk of death for the existing ED's patients.
The Bottom Line: Many studies have attempted to determine the impact of boarding and to tie boarding to morbitiy and mortality. This author's unique approach to the problem serves to reinforce the need for comprehensive solutions to the problem of patient boarding. Even a modest reduction in emergency department volume has a measureable impact on patient outcomes
Physician Workforce Diversity in EM
Health inequities along racial, ethnic, and socioeconomic lines are a brutal reality of the current state of health care in the US. One way to attempt to address these inequities is to make a concerted effort to diversify our physician workforce. As authors have noted, “Having physicians from diverse backgrounds as colleagues and role models can promote understanding and tolerance in nonminority physicians, ultimately improving medical care for patients who are part of these racial and ethnic groups. Increasing the population of underrepresented minority (URM) physicians in the workforce also directly improves health care for medically underserved populations from all racial and ethnic backgrounds, as studies have shown that physicians from URM backgrounds are more likely to work with these patients.”
Administrators are often tasked with the difficult job of creating a cohesive group of emergency physicians to meet the needs of the community they serve. Strategies to diversify that workforce would benefit from a multi-level approach, including the following:
Small steps can create big changes.
Since the switch from fee for service to value based care in the US, there has been a marked push to improve our documentation to expand our MDM and differential considerations. We are all here becoming adept at the medical documentation (thanks Dr. Adler!), but may not be adequately documenting our patients' social determinants of health using the social Z codes, a subset of ICD-10 coding language
This study wanted to look at the overall prevelance of social Z code utilization. They used the Nationwide Emergency Department Sample (NEDS), a nationwide database of ED visits, to look at this particular documentation. They examined 35 million (!) ED visits and found that only 1.2% had any social Z code included in the documentation. Given how many resources are linked to a verified (eg documented) need, this raises the idea that if Z codes are better documented, this may lead to increased funding for things like food, housing and transportation insecurities.
Limitations- the authors only examined the ED visits for ICD-10 codes, they didn't specifically look at the notes themselves which may have contained SDOH information. They also found that the social Z codes were more often documented in visits coded for mental health diagnoses, potentially indicating bias. There is also the concern that patients may not want the social z codes included, given the stigma around things like homelessness.
Overall, social Z code documentation could potentially unlock better resources for our patients by documenting a specific need in a population. More will come as documentation continues to evolve.
The WHO and the US Department of Health and Human Services, among other groups, recommend between 150-300 minutes of moderate intensity or 75 to 150 minutes of vigorous intensity physical activity per week.
This could add up to almost 45 minutes a day!
Who has the time for that?
This is an extremely challenging goal with work and other life responsibilities.
Some recent studies asked whether routinely cramming the recommended weeks’ worth of physical activity into a couple of days, weekend warriors (WW), leads to the same life-extending benefits as distributing the exercise load throughout the week.
In a retrospective analysis of almost 90,000 individuals (56% women), providing a week of accelerometer-based physical activity data: Three activity patterns were compared: active weekend warrior (active WW, ≥150 minutes with ≥50% of total achieved in 1-2 days), active regular (≥150 minutes and not meeting active WW status), and inactive (<150 minutes).
A weekend warrior (WW) pattern of physical activity was associated with similarly lower risks of cardiovascular outcomes (incident atrial fibrillation, myocardial infarction, heart failure, and stroke) compared with more evenly distributed physical activity.
Another large prospective cohort study of over 350,000 US adults (51% women) did not find any significant difference in mortality rates between weekend warriors and regularly active participants. Compared with physically inactive participants, active participants (both weekend warrior and regularly active) had lower all-cause and cause-specific mortality rates.
Take home: Any exercise is better than none. Adults who perform 150 minutes or more of moderate to vigorous physical activity (or 75 minutes of vigorous activity) per week may experience similar health benefits whether the sessions are spread throughout the week or concentrated in a weekend.
Note: Being a weekend warrior can increase the risk of MSK complications and injury..
Future studies should include the use of wearable devices and not rely on self-reporting exercise behavior.
In a recent study of emergency physicians (EPs) who left the workforce between 2013 and 2020, authors sought to investigate their age and number of years since residency graduation for males and females.
A total of 25,839 (70.2%) male and 10,954 (29.8%) female EPs were included.
Female gender (adjusted odds ratio 2.30) was significantly associated with attrition from the workforce.
Of those who left the workforce, the median number of years after residency that males left was 17.5, as compared with only 10.5 years for females.
Furthermore, among those who exhibited attrition, one in 13 males and one in 10 females exited clinical practice within 5 years of residency graduation.
As authors emphasize, these data identify widespread gender-based disparities regarding EM workforce attrition that are critical to address to ensure stability, longevity, and diversity in the EP workforce.
